Handwashing and HAIs: What's Holding Us Back?

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A nurse who survived a severe hospital acquired infection and the physician who created healthcare's well-known "My 5 Moments for Hand Hygiene" program discuss the stubborn nature of handwashing compliance and tips for hospitals to improve it.

Ellen Hargett, RN, is not the typical patient. She's director of process improvement at Atlanta-based DeKalb Regional Health System. That's why, when she became a cancer surgery patient at her own hospital, she was fully aware of the risks of the operation. However, she never expected to fall victim to a severe surgical site infection.

Ms. Hargett contracted an unusually severe case of methicillin-resistant Staphylococcus aureus, a bacteria often transmitted through improper hand hygiene, after a second operation to correct complications from the initial cancer surgery. She battled sepsis and an abdominal abscess for many months following the second surgery. Ultimately, she was informed her last option was a third surgery that would leave her abdomen open for a week. She said yes. It saved her life.

While Ms. Hargett was able to return to work after eight months from the initial surgery, her ordeal left her with lifelong chronic complications and incredible insurance expenses. Her cancer surgery cost $79,000. Expenses related to her care as a result of her MRSA infection totaled $239,000.

Ms. Hargett is surprisingly positive about her experience as a patient, noting she used the time to think about the state of infection control. While on the mend, she began an informal tally of infection control opportunities. "I noticed it was about 30 percent of the time that people carried out elements of infection prevention [including hand hygiene]," she says. "Later I learned that standard of performance was not unique to our hospital."

Didier Pittet, MD, director of the infection control program and the Collaborating Center for Patient Safety at the World Health Organization, says Ms. Hargett's story is not uncommon, though most hospital-acquired infections are less severe. Dr. Pittet was responsible for heading up the team that developed the 2005 internationally-utilized WHO tool, "My Five Moments for Hand Hygiene." He and Ms. Hargett spoke at a conversation about hand hygiene sponsored by DebMed, a company engineering solutions for hand hygiene compliance.

Unfortunately, hospital-acquired infections are a daily reality in healthcare settings. In the U.S. alone there are nearly 100,000 HAIs creating $35 billion to $45 billion in extra costs to the healthcare system. Worldwide, 15 million patients die from HAIs every year. These statistics, according to Dr. Pittet, are exactly why hand hygiene is priority for the WHO.

The "My Five Moments for Hand Hygiene" program is in place in more than 170 countries worldwide, and it has proven effective in every country and culture. It recommends healthcare workers clean hands before touching a patient, before aseptic procedures, after body fluid exposure or risk of exposure, after touching a patient and after touching patient surroundings.

Despite its potential effectiveness, the program suffers from low compliance — between 10 and 40 percent. This is a known effect: Healthcare workers imagine hand hygiene compliance twice as good as the reality. According to Dr. Pittet, this is because hospitals are simply not ready to commit to safety cultures that help healthcare workers have consistently great hand hygiene compliance.

Ms. Hargett mentions a related concept, the Hawthorne Effect, coined in a 1950 paper on worker productivity, in which study subjects behaved differently when a researcher was present, thereby biasing outcomes in the original study. Here the Hawthorne Effect means hand hygiene compliance is great in research settings, but compliance slumps when studies conclude.

This is somewhat dismaying, considering science has definitively shown HAIs are preventable through appropriate hand hygiene at the point of patient care. "Systemic change is necessary," says Dr. Pittet. "We have the tools, now we must push safety culture. Every bit counts." He suggests several points necessary to permanently improve compliance.

1. Ensure the hospital has a commitment to improving compliance through any means necessary.

2. Monitor the performance of healthcare workers' hand hygiene practices. The most frequently used technique for this step is bedside monitors, but electronic or automatic systems are also appropriate.

3. Share hand hygiene performance information among peers and peer groups to stimulate patient safety culture surrounding hand hygiene.

4. Verify that healthcare workers are appropriately educated on transmission of pathogens through touch.

5. Ask patients and families to remind healthcare workers of the importance of good hand hygiene practices.

Dr. Pittet recommends hospitals use the WHO's self-assessement for hand hygiene safety culture to see how they can improve on an individual level. Although accountability is important, he stresses that leaders or clinicians should never accuse individual healthcare workers in the compliance improvement process. "The hospital itself is responsible for the behavior of its healthcare workers," he says.

More Articles on Quality:

Flip the Clinic: Transforming the Physician-Patient Interaction

Implementing and Sustaining Process Improvement: 6 CMOs, Chief Quality Officers Weigh In

Do Hospitals Have an Attitude Problem?  Shifting the Focus to Population Health

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