Hand Hygiene Compliance Strategies from ICT Readers

ICT asked infection preventionists to share some of their best strategies for boosting hand hygiene compliance at their facilities.

There’s one thing Nash Health Care’s infection prevention coordinator doesn’t mind spreading throughout the facility — news that handwashing prevents infection and saves lives. Wanda Lamm, BSN, CIC, has been infection prevention coordinator at the Rocky Mount, N.C. facility for 18 years, where employees from all disciplines have gone the extra mile to promote and practice proper handwashing.

It’s not unusual to see blue buttons, computer screen savers, window clings and fliers throughout the 353-bed hospital system declaring, “Ask. Learn. Clean.” These reminders, which feature a handprint, are not just an important reminder of patient safety, they are declarations that at Nash Health Care, a member of VHA Inc., employees practice what they preach.

An infection prevention initiative has utilized “secret observers,” healthcare employees who silently survey areas for appropriate handwashing techniques and submit the data to Lamm. From there, the data is categorized and reported monthly to hospital managers, administration, and to the staff — creating a dose of healthy competition between units to identify the most compliant performers.

“Compliance rates are reported by disciplines and by departments, so that everyone sees how others are doing,” Lamm says. “I believe having staff members participate in collecting observations raises their awareness of what is really happening in their units.”

The methods are working; not only has Nash Health Care seen a decrease in methicillin-resistant Staphylococcus aureus (MRSA), but handwashing compliance has increased from an average of 69 percent for 2007 to 87 percent for 2008. In addition, since September 2008, handwashing compliance has averaged more than 90 percent before and after patient care. While the most recent data for 2009 is still being processed, preliminary estimates indicate that compliance is hitting around the 94 percent mark, placing Nash Health Care closer to its goal of 95 percent.

While a 90 percent handwashing compliance rate is in line with Joint Commission standards, Nash Health Care wanted to take patient care to the next level.

“Doing a good job is simply not good enough,” Lamm says. “We want to provide superior quality care and provide a culture of safety where employees approach others prior to failure to wash hands. This is why our infection prevention committee made the recommendation of a 95 percent compliance goal. Employees have embraced the program and are demonstrating outstanding teamwork, from nurses to physical therapists to transporters to physicians.”

Melanie Palker, RN, BS, an infection preventionist at Doctor’s Hospital at Renaissance in Edinburg, Texas, says her facility is currently installing screensavers with a hand-hygiene message on computer terminals at nursing stations and at all other patient-care areas throughout the institution. Palker explains that one of the facility’s physicians will serve as the screensaver’s “spokesdoctor,” called Dr. Germ A. Cide.

“We hope to roll out screensavers hospital-wide to promote infection prevention topics,” Palker says. “A series of three or four slides will be added and changed every couple of months to keep interest up -- it will have a soap-opera feel to it. So far, the people who have seen the screensavers like the idea. It will be especially nice having one of our own physicians with various facial expressions and changes indicating approval or frowning, etc. according to the message. Next, we will address the topic of washing lab coats more frequently. We will try to tie in the screensavers with whatever is making news as it pertains to infection prevention and control in our institution.”

Changing healthcare workers’ attitudes is essential to improving hand hygiene compliance, says Maureen Spencer, RN, MEd, CIC, infection control manager at New England Baptist Hospital in Boston. “It is key to change attitudes and beliefs, establish role models and provide opportunities for staff and physicians to model appropriate behavior, like hand hygiene.”

Having a presence on the floor can be a big help, too. Spencer says she conducts monthly patient tracer rounds with the nurse managers. She relays a recent experience from a rounds: “One of the clinical nurse leaders was cleaning the nursing station computers; on another rounds, a nurse practitioner was wiping off her stethoscope; and on yet another rounds, a nursing assistant was wiping down the blood pressure equipment. That is exactly what we look for! I went around and filled up the empty baskets on the patient monitor machines with germicidal wipes, and placed alcohol wipes near all of the computers. Staff observe this and model it. ‘We are all in it together” is our theme.”

Joseph M. O’Neill, OPA-C, CSA, believes that hand hygiene, in regard to the prevention of healthcare-acquired infections, is one-half of the complete solution even if compliance was 100 percent. “I think the other half of the solution is to prevent re-contamination of one’s hands,” O’Neill says. “Why don’t we give the same amount of emphasis to disinfecting the patient’s environment? This way of thinking would keep our hands aseptic longer as we work in a patient area.”

O’Neill suggests using technology: “One idea to increase compliance is to attach an electronic light beam detector at the doorway of every patient room or critical area, similar to the ones found on home garage door openers. That sensor could be wired into an automatic alcohol dispenser. If you do not wash before entering or leaving the room, a flashing light would go off. That light could only be turned off by a hospital supervisor."

Tarry Samsel, RNC, BSN, from Morristown-Hamblen Healthcare System in Tennessee, relates a long journey through the experience of trying to improve hand hygiene compliance: “When I started in infection control we simply measured hand sanitizer usage. Of course the only thing you can tell by that graph is when the Joint Commission visited. Next, we started our hand hygiene observation campaign. Of course, when I say we, I mean me. I was the only one observing hand hygiene, and that was done after infection control duties and employee health duties, as I wear both of those hats for a 167-bed facility. Then after much whining and fussing, I convinced my chief nursing officer to have each director submit hand hygiene data for each unit on a form eerily similar to the Vanderbilt document that was available online. I now can tell the compliance rate for each unit on a monthly basis, but I am in control of more than 30 graphs submitted to the committee. I send letters of thanks to anyone who is reported for doing well, and I send letters to those who are noncompliant -- nurses and docs alike. I now actually see staff using the sanitizer as I walk down the hall. My crowning achievement was when a physician said to me, ‘I am afraid of you!’ with a smile on his face.”

Carol Mangles, RN, BSN, CIC, infection prevention and control supervisor at Barnes Jewish St. Peters Hospital, reports that at her 100-bed community hospital that is part of large BJC system, they had struggled with hand hygiene compliance rates stagnating in the 80 percent range. “In late 2007, a decision was made to begin collecting the names of the compliant and noncompliant healthcare workers who were observed that month,” Mangles says. “We typically collect 120 to 200 hand hygiene observations each month from our inpatient units, emergency department, and pre-op/post-op areas. To soften the idea of collecting names, we developed the Hand Hygiene Hero (HHH) award program beginning in February 2008. Monthly, in the cafeteria during lunch time, the names of one to three compliant healthcare workers during the previous month are drawn to win a monetary gift. We also post their photos on a screensaver that is sent out to all hospital computers, and we post the printed photos on our HHH bulletin board outside our cafeteria. Their names also go into our monthly newsletter. These activities help keep hand hygiene in healthcare workers’ minds and reward our compliant ones. The names of the noncompliant healthcare workers are forwarded to the appropriate manager for discussion and re-education. Physicians and LIPs are also included. Noncompliant LIPs are forwarded to the credentialing committee. Compliant LIPs are also noted on their individual quality reports. Our observers who are collecting the hand hygiene observations are also handing out ‘You have been spotted!’ cards; we have a noncompliant card and a compliant card (it’s good for a $2 treat in the cafeteria). After making these changes, we have seen our monthly compliance score increase to the mid-90s. We ended our year-end (2008) rate at 93 percent.”

In late 2007, Tufts Medical Center was committed to improving its less-than-satisfactory hand hygiene compliance rate of 71 percent. The obvious risks to patient safety, along with an impending visit by the Joint Commission, led Tufts to launch a comprehensive hand hygiene program in March 2008. The hospital had tried smaller, generic, uncoordinated programs in the past with little success. A coordinated, consistent effort was need to add to the strong commitment of the senior medical leadership. A creative, unique approach was necessary to cut through the clutter. Working together, Tufts Medical Center and Jennings Co., healthcare marketing firm, created the Speak Up Wash Up hand hygiene campaign, according to Dan Dunlop, president of Jennings Co.

“We designed the Speak Up, Wash Up campaign to blanket the hospital while providing fun and informational messaging,” Dunlop explains. “Using a speach bubble theme, we created a culture that was lively and fun. At the same time, we empowered everyone in the hospital to speak up and promote hand hygiene to each other. By keeping hand hygiene fun and top of mind, compliance was easier to promote.”

Speak Up Wash Up collateral material included:

· Decals that were placed on hospital and bathroom walls, near hand hygiene stations, break areas and distributed to patients.

· Fliers that were available to inform patients about what they were seeing.

· Posters that were hung near elevators and in units.

· Buttons that staff members wore to promote hand hygiene.

· Internal e-mail blasts to employees and monthly articles in employee newsletter that were used to keep the staff up to date on the improved compliance.

The overall program included:

· Assessment of hand hygiene compliance following the recommendations of the CDC by unannounced direct observation on each inpatient unit by monitors who received training by infection control staff

· Monthly feedback of comparative hand hygiene compliance by nursing unit via e-mail to all employees.

· Strong support from the medical center leadership.

· Patient safety champions on every unit (physician and nurse)

· Hand hygiene lecture for all employees with post test

· Annual updated education for nursing staff

· Educational lectures by infectious disease staff

· Enhanced distribution of hand sanitizer dispensers

“By the end of the campaign’s first month within the medical center, Tufts Medical Center’s compliance had increased to 90 percent,” Dunlop says. “By December 2008, the compliance rate had improved to 97 percent with 11 units scoring a perfect 100 percent. During the Joint Commission’s five-day visit to Tufts in August 2008, they did not find a single hand-hygiene violation. The Joint Commission commented on the creativity and pervasiveness of the campaign.”

Phyllis Theodos of Cancer Treatment Centers of America in Zion, Ill., reports that she noted low hand hygiene compliance rates during direct observation by secret shoppers (volunteers and nursing students). “In order to verify the data, I began weighting the alcohol-based hand sanitizer product in the same rooms on a weekly basis. Unfortunately, the results were just as dismal. I selected hand hygiene as a Greenbelt project to try to look outside the box at implementing a variety of ideas to increase compliance. For example: during drive-by’s on all shifts, stakeholders voted on a new product, a foam instead of a gel.”

Theodos lists other strategies:

· New posters were made using stakeholders and placed throughout the organization

· A hand hygiene orientation PowerPoint using stakeholders was developed

· Drive-by education with petri dishes growing ‘ick’ from stakeholders’ hands and environmental surfaces

· Articles in the facility’s in-house magazine

· Hand hygiene product and a patient hand hygiene guide attached for the taking in the front lobby

· An antibacterial wipe provided on food trays with a patient education reminder to use before eating

· Department education, with emphasis on environmental surfaces

· Stakeholders’ input into where hand sanitizer dispensers should be located

· A reminder on the electronic message board to perform hand hygiene

Theodos says that the results so far have been “far from desired” and is contemplating using tougher tactics. “My next step is to be a beta site for a tracking device that is a RFID reader of the name badge whenever a stakeholder enters the patient room. It tracks compliance at the same time as giving a live message, such as, ‘Patient is a fall risk.’ It also gives reports as to personal compliance, unit, department etc. It was installed in two rooms for beta testing in late April. I am looking for data to bring back to department heads to say, ‘this stakeholder needs increased education, or if not improved, discipline.’ It also will take the subjectiveness out of the observations and the error out of the measurements. I have my (clean) fingers crossed that the beta performs as we are hoping.”

Joewayne Asuncion, RN, BS, the staff education nurse working in a new hospital in Saudi Arabia, collaborates closely with the facility’s infection control nurse and quality management nurse to address key infection prevention issues. “Our infection control nurse is very active in campaigning for improved handwashing,” Asuncion says. “We also produce a calendar-like poster stating the WHO’s Five Moments of Handwashing. We distributed this to all inpatient units and placed one each room in the outpatient clinics. We also provide a general infection control tool inside of our patient rooms.Moreover, the infection control nurse conducts environmental rounds every day with the safety officer and the quality management nurse. In our institution we believe that education is the key to a successful campaign in preventing healthcare-acquired infections.”

Dawn Canterbury, MT, who works in infection control and occupational health at Logan Regional Medical Center in Logan, W. Va., describes her experience as she made rounds in her 132-bed facility: “Staff learned early on when I was out doing surveillance rounding that I was observing hand hygiene compliance; so on my rounds I was getting 100 percent compliance 100 percent of the time, which we know is not accurate. I even had one physician who was so paranoid, that every time he saw me in the hallway (what he called “patrolling”) he would either stop and use hand sanitizer or soap and water. So to get a more accurate picture of what was really going on, I involved peer monitoring through direct observation. Every month I try to do 10 to 20 audits myself, then employ five other healthcare workers to do 10 audits. I choose different departments each month, select one person, give them an audit sheet and a letter explaining to them how to perform the monitoring, and how to return the form back to infection control. The spies’ names are never revealed, and doing it this way I am getting a more accurate picture of what is going on out there 24/7. The biggest culprits, of course, are physicians, so I have them performing the peer monitoring as well — they love telling on each other. So far, this is working well for us.”

Nancy J. Haberstich, RN, MS, an infection preventionist, health educator and consultant in Lincoln, Neb., says that one of the biggest obstacles to hand hygiene compliance is healthcare workers’ burnout on the topic. “We have been preaching hand hygiene for 40-plus years and it is now part of the educational curricula of health professionals, an important focus in hospital orientation programs, and an obvious component of performance improvement, but it has obviously not become a habit,” Haberstich says. “It seems to me that it is time to try new strategies that move caregivers to self-directed compliance. We may have painted ourselves in a corner with the strategy of ‘evidence will promote compliance.’ I have searched for a strategy to prevent audiences from rolling their eyes back in their heads and tuning me out. I was one of the first ICPs to utilize GloGerm to get the attention of hospital employees and bring home the importance of proper technique. I think this is still a good element to be included in a hand hygiene compliance strategy. But another important element is knowledge for the owner of the hands (OOTH). By that I mean ‘applied microbiology,’ adapted to the owner of the hands. As infection prevention has evolved to include so many new and old and adapted microbes, that knowledge has been effectively assimilated into the thinking of the infection preventionist but the rest of the employee population has been busy assimilating other knowledge critical to their practice. It seems that there is no interest in adding microbiology to their knowledge base, and most of us can’t remember the microbiology we learned in our professional training.”

Haberstich explains that she created the concept of nanobugs to entertain and educate about practical microbiology for the purpose of infection prevention and health promotion. “It was important to capture the character of the microbe with the cartoon image and to maintain the scientific integrity of the concept and the nanobugs, themselves, in order to use them to teach and train,” she says. “They are not just little doodles that trivialize the need for hand hygiene. Rather, they explain, often with their morphology, what action is needed to control or eliminate them. A growing number of infection preventionists are using nanobugs for teaching and training diverse employee, patient and family member populations. The response to these ‘microbes with attitude’ is much more positive and seems to be more compelling than another review of the evidence or the rules. Cartoons, animation, humor, tattoos, and card collections are hot now and can get the attention of Generation X employees, as well as those on both sides of them on the age spectrum. A prominent U.S. naval hospital used the nanobugs for their infection control in-services last year; their compliance team wore T-shirts and led the singing of the nanobugs songs to conclude the in-services. Some hospitals have revived the bug-of-the-month concept with the Nanobug-of-the Month subscription. I think it is time for a fresh new approach to this age-old problem.” Visit http://www.nanobugs.com/

William P. Sawyer, MD, a family medicine practitioner in Cincinnati, is the creator of HenryTheHand.com, a Web site that champions hand hygiene, respiratory etiquette and cross-contamination prevention using the character, Henry the Hand Champion Handwasher as the messenger to “Spread the word not the germs!” Sawyer developed the program over the past 20 years to raise “hand awareness.” For more details, visit: http://www.henrythehand.com/

Novant Health in Winston-Salem, N.C. won the 2008 Ernest A. Codman Award from The Joint Commission for its successful efforts to improve hand hygiene compliance and reduce the spread of methicillin-resistant Staphylococcus aureus (MRSA). “Washing hands seems like such a simple task,” says Paul Wiles, CEO and president of Novant Health, “but it took a relentless and creative solution to improve our health system’s hand hygiene compliance. We were honest with staff, telling them that we could save patient lives if we were all successful. And now we know that our improvement spared patients from the complications of MRSA.”

Compliance at Novant increased from 49 percent to 99 percent in just two-and-a-half years, and the behavior change led to a 53 percent reduction in hospital MRSA infection rates across the healthcare system. That reduction means that 249 patients from 2005 through 2008 did not suffer the medical complications of MRSA.

The hand hygiene campaign began in 2005 and involved every employee. Policies and processes were updated, additional staff was hired to support the initiative and the system used an edgy but honest internal communication campaign that included screensavers, cling stickers, billboards, yard signs and other tactics to educate and help change behavior.

Novant has received inquiries from hospitals around the country and decided to create a Web site where interested organizations can download for free materials used in the hand hygiene project. To date, more than 300 healthcare facilities have used Novant’s materials to improve hand hygiene in their own institutions. Visit http://www.washinghandssaveslives.org/.