Next Steps in Patient-Centered Hand Hygiene: Insights From Hospitalized Patients

By Kay Temple

The human body is home to more than 10,000 different microbes. Researchers with the NIH Microbiome Project say they've identified almost 99 percent of the microbes that live in and on the body. Many of these microbes are known pathogens, docile and peacefully coexisting with their neighbors. But healthcare workers (HCWs) know one thing to be true: those pathogens cannot be trusted. In the blink of an eye, pathogens can morph into the causative agents of healthcare-acquired infections (HAIs) and take a patient's life.

Over the past several decades, HCW hand hygiene has emerged as a core prevention against microbial pathogens and HAIs. The World Health Organization (WHO)'s 2009 monograph, "Guidelines on Hand Hygiene in Health Care" say that though there is a "lack of scientific information on the definitive impact of improved hand hygiene compliance on HAI rates...there is convincing evidence that improved hand hygiene through multimodal implementation strategies can reduce infection rates." The Joint Commission Center for Transforming Health Care has carried this multimodal implementation strategy even further with its "Hand Hygiene Project" by suggesting targeted solutions using the mnemonic "hands:" habit, active feedback, no one excused, data driven, and systems.

No One Excused
No one is excused from engaging in proper hand hygiene. Not nurses, not physicians, not volunteers, perhaps not anyone who steps into a hospital or ambulatory health setting. Common sense dictates that patients should also be on that list. Patients are not only passive recipients, they are active transmitters of pathogens and can't be excused from these multimodal strategies involving hand hygiene. Starting first with the patient empowerment movement, getting patients to speak up and give feedback to HCWs who are not following hand hygiene rules has proved effective. But researchers understand there is no time to waste in getting to next steps for integrating patients into further hand hygiene efforts. As learned from early studies on HCW hand hygiene practices, these next steps will start by gaining insight into patients' mindsets about their personal hand hygiene habits and philosophies.

Patient Hand Hygiene Practices: At Home and in the Hospital
A University of Wisconsin, Madison, research team took that logical next step by studying hand hygiene in 207 patients admitted to their university hospital between October 2012 and May 2013. The results of their cross-sectional, interviewer-administered survey, "Patients' Hand Hygiene at Home Predicts Their Hand Hygiene Practices in the Hospital," are published in the May issue of the journal Infection Control and Hospital Epidemiology. Nasia Safdar, MD, PhD, associate professor and infectious disease specialist involved with the study, says the study's design originated from efforts to further decrease Clostridium difficile-related HAI infections.

"The whole country is struggling with Clostridium difficile rates and we know the transmission is fecal-oral," Safdar says. "The patients' involvement as part of the whole transmission chain from their hands to their mouth and into their intestines was a question that came from the healthcare workers. So we thought we should look and see if patients are behaving differently when they are hospitalized as opposed to when they are home with respect to hand hygiene."
Excluding patients less than 18 years of age, those in the intensive care unit or with cognitive impairment, the team focused on factors associated with typical hand hygiene practices. For study purposes, "handwashing" was defined as using either soap and water, alcohol-based sanitizers, or antibacterial wipes. The team's analysis showed statistical differences between home and hospital-based hand hygiene practices with regard to always washing their hands before eating and always washing their hands after using the restroom.

When at home, 85 percent of patients say they always wash their hands after restroom use. But after hospitalization, that percentage fell to 69.5 percent. Asking the corollary "never washing after restroom use," the home percentage of 1 percent increased to 10.5 percent after admission to the hospital.
Statistical differences were even greater with hand hygiene practices before eating. At home, 64.7 percent "always" wash their hands prior to meals, but after hospitalization, that percentage dropped to 41.4 percent. Again, the partner "never" question revealed that never washing hands before meals at home occurred in 2.9 percent of the survey patients, and after hospital admission, the "never" group rose to 22.2 percent.

Since patients are exposed to potential pathogen reservoirs as they come and go from their hospital rooms all day, the Wisconsin researchers also asked patients about their handwashing before entrance and after exiting their hospital rooms. The survey found approximately 60 percent of patients never used hand hygiene on either of these occasions. The researchers noted the absence of that practice applied to many of the patients who were in the "always" category for hand hygiene before eating and after toileting.

Of course, a patient's ability to both understand the need for handwashing and physically accessing hand washing implements (sinks, hand sanitizers, wipes) does influence hand hygiene practices, especially in the hospital setting. And today's hospitalized population often includes patients with temporary or chronic cognitive impairment along with temporary or chronic immobility. This prompted the Wisconsin team to also look at the latter category. They found that "while many patients cited limited access as a cause for poor hospital hygiene, mobility problems hindered hand hygiene improvement in the hospital only for patients who had poor hand hygiene practices at home. Among patients who always washed at home, the percentage with declining hygiene was the same, irrespective of mobility."

The Fundamental Question
The Wisconsin study highlights the power of patients' personal handwashing practices. No longer considered an abstract philosophy, patient engagement and its importance for hand hygiene has been defined. Implementation strategies are being perfected. Many of these strategies have focused on patients' monitoring of HCW behaviors alone. But the hands of patients themselves are prominent links in the HAI transmission chain that can't be ignored.

The authors of a May 2012 review in the American Journal of Infection Control, "Patient-Centered Hand Hygiene: The Next Step in Infection Prevention," have suggestions for those strategies. Mirroring the WHO's "Five Moments," they provided a list of nine patient moments for specific hand hygiene actions, ranging from moments of hand hygiene after toileting to before and after interacting with visitors.

The AJIC review also suggests that next steps should perhaps start with a very simple, fundamental question. "Although some studies have suggested that patients' poor hand hygiene can be attributed to lack of knowledge, perceived importance, impeded movement, and physical impairments, the fundamental question may be whether or not patients are encouraged to clean their hands at all."

That fundamental question--whether or not patients are encouraged to clean their hands--also surfaced during the Wisconsin study, according to Safdar. "When patients are ill and have a lot of other things on their mind, hand hygiene isn't a high priority," Safdar says. "The perception by our patients was that if it is important to me, the patient, then somebody should have emphasized it. If they didn't, then it clearly wasn't that critical."

Solutions From the Field
Safdar says that efforts to improve hand hygiene must involve the patient perspective. "We must remember two aspects," she says. "The role of the patient in promoting healthcare worker hygiene, and the role of the patient in promoting their own hand hygiene." With this in mind, the Wisconsin researchers also engaged their study patients to determine what might work to bridge hand hygiene lapses identified in the survey. "The patients will tell you how they want questions answered," Safdar says. "Incorporating them right from the beginning will help to develop interventions that are likely to work."  In their study, almost 90 percent of the patients thought bedside gel sanitizer and food tray hand wipes would be helpful. A reminder poster in rooms was supported by nearly 75 percent, while 60 percent approved HCWs physically washing patient hands.

Patients were not as keen on support from HCWs, with only about 80 percent of patients wanting more direct assistance from HCWs. Nearly 75 percent were in support of more frequent reminders from HCWs, but only 60 percent wanted HCWs to physically wash their hands.

The Wisconsin study is one of the first to specifically look at patients' hand hygiene behaviors at home and in the hospital. The authors note their study "provides insight into the developing field of patient-centered hand hygiene." Understanding how hospitalization changes patient handwashing practices combined with patients' insights for solutions suggests while patients are experiencing real time hand hygiene hospital moments, they can provide valuable information for next steps to patient-centered hand hygiene.

The authors of the 2012 AJIC review say that "if patient hygiene is to become a clinical reality and have an impact on patient safety and the reduction of HAIs, clear guidelines and a range of support must be established to promote patient hand hygiene behavior." Their review provides a framework of considerations for patient hygiene promotion, circling back yet again, to the potential strengths of the multimodal strategies that "identifying opportunities to coordinate efforts to promote the need for and methods of patient hygiene to the participants in the healthcare setting--HCWs, patients families and visitors alike."

Earlier this year, the Centers for Disease Control and Prevention (CDC) reported impressive decreases in HAIs associated with central lines and surgical site infections. But, according to information in a recent March 27 New England Journal of Medicine report, "Multistate Point-Prevalence Survey of Health Care-Associated Infections," based on 2011 data, on any given day in a U.S. hospital, there is still approximately one of every 25 inpatients with an HAI.

Initiatives for hand hygiene practices will hopefully continue to improve these HAI statistics by making sure the fundamental question is asked and answered by HCW and patients alike: have you washed your hands?

Kay Temple is a writer for ICT.

The 2009 World Health Organization’s “5 Moments for Hand Hygiene:”
 1. Before patient contact.
 2. Before aseptic task.
 3. After body fluid exposure risk.
 4. After patient contact.
 5. After contact with patient surroundings.

Proposed 9 Moments for Patient Hand Hygiene, from “Patient-centered hand hygiene: The next step in infection prevention,” AJIC, May 2012.
 1. After using the toilet, bedpan, or commode.
 2. When returning to room after test or procedure.
 3. Before eating, drinking, taking medicine, or putting anything in your mouth.
 4. When visibly dirty.
5. Before touching any breaks in the skin (e.g., wounds, dressing, tubes) or any care procedures (eg, dialysis, IV drug administration, injections.)
 6. Before dialysis, contact with IV lines or other tubes.
7. After coughing, sneezing, or touching nose or mouth.
 8. Before interacting with visitors and after they leave.
 9. When there is concern about whether hands are clean.