When Patients Become Hand Hygiene Police

Opportunity often rides the back of a crisis, and a common enemy often forges interesting alliances. Hand hygiene is one of the Big 3 “low-tech” infection prevention tools much touted since the arrival of the coronavirus disease 2019 (COVID-19), along with social distancing and wearing a mask. But hand hygiene compliance rates among healthcare workers have always been underwhelming and trying to overcome that problem remains one of the more intractable challenges of an infection preventionist’s job, even in the COVID and coming post-COVID era. A study in the American Journal of Infection Control suggests that IPs might want to consider enlisting patients in that effort.

Investigators with CancerCare Manitoba in Winnipeg, Canada, concluded that hand hygiene auditing programs by nurses and by patients can complement each other, and lead to better compliance. Investigators state that “our observations have re-affirmed the value of patient engagement in the HHC [hand hygiene compliance] monitoring process consistent with the 5 strategic steps for successful multimodal HH [hand hygiene] advocated by the World Health Organization. We were able to identify the complementary roles for the nurse and patient auditors within a provincial ambulatory cancer care facility. Further, we found that the patient audit process was sufficiently robust to permit discrimination in compliance rates over time by professional group and by different multidisciplinary teams.”

Of course, the Hawthorne Effect came into play; the hand hygiene rates were higher when healthcare providers knew they were being watched. Over the 10 study periods, the healthcare providers were told that nurses would be auditing them, although they weren’t given specific details. Healthcare workers were told that some patients would also be auditing them. One group of patients conducted the auditing covertly—that is the healthcare workers didn’t know that they were being audited; the other group of patients audited overtly.

“The range of our nurse audit outpatient HHC rates (84% to 96%) was similar to that reported for overtly conducted inpatient audits (87% to 90%), but higher than the 24% to 63% range reported in covert independent audit studies,” the study states. “The range of our patient audit HHC rates (57% to 82%) was lower than that reported by patient auditors in ambulatory family practice-based settings (88% to 97%).”

The healthcare providers audited included a large swathe of professionals including “faculty physicians (medical, radiation, and surgical oncologists; haematologists; family physicians in oncology; physician trainees; and physician assistants), nursing team members, and other HCP (laboratory phlebotomists, radiation therapists, clinical pharmacists, and allied HCP such as social workers, occupational therapists, physiotherapists, clinic clerks, and nursing assistants).”

The auditors were told to be as unobtrusive as possible and could only do their auditing before the providers entered a patient’s room or after a provider exited a room.

“The patient-driven audit process was conducted over approximately a 2-week mid-quarter period…” the study states. “Briefly, patients who were attending scheduled clinic appointments, receiving systemic therapy or radiation therapy treatments, or undergoing phlebotomy were invited to voluntarily participate in the audit at the time they reported for the appointment. Consenting patients were asked to complete a standardized form by answering ‘yes’ or ‘no’ to the question, ‘Did you see us clean our hands today before and after your examination or treatment visit?’”

It’s one thing for an IP to remind a healthcare worker to wash their hands. It’s another for a cancer patient to do so. “The results of the supplemental survey suggested that our patients felt that [hand hygiene compliance] among their [healthcare professionals] was very important and that participation in the monitoring process for compliance was valuable. Almost half (45.9%) of patients were disinclined to remind their [healthcare professionals] to clean their hands had they not seen them do so notwithstanding the range in the strength of the responses related to this point.

The investigators say that their findings underscore the importance of encouraging and “empowering” patients to be a part of efforts to improve hand hygiene compliance among healthcare workers.