Limited Research Need Not Deter From Involving Patients in Hand Hygiene

The idea of involving patients in provider hand hygiene compliance is a relatively new one. It's been around for a little more than 15 years but has picked up most of its momentum in the last decade. The original idea of being partners in care, however, comes from a 1997 paper by McGuckin et al., reporting on an intervention that encouraged patients to ask providers if they had washed their hands.

The McGuckin study showed that while patients were interested in the concept, they didn't often follow through. When they did, they rarely asked physicians, opting to ask nurses instead. Despite the limited success of the intervention in the study, it sparked a new emphasis on involving the patient in provider hand hygiene. Now the concept has spread throughout the healthcare world from tiny community hospitals to the World Health Organization.

Interestingly, there is little research on how effective the intervention technique is for reducing infection. According to Gina Pugliese, vice president of Premier Healthcare Alliance's Safety Institute, the intervention is simply another in a long line of strategies aimed at improving provider hand hygiene compliance, which has included tactics as different lights, electronics, signage, voices and even artwork.

Though almost 20 years have passed since the McGuckin study, Ms. Pugliese notes that there is still a lack of willingness to ask providers to wash up. Multiple studies have documented the low percentages of patients willing to ask providers to wash or re-wash their hands, despite the fact that patients seem to know how important hand hygiene is for infection prevention. One study found that patients were more willing to ask questions about medications or reasons for receiving a particular procedure than to ask a caregiver to wash his or her hands.

To combat this foot-dragging, there are many ways hospitals ask patients to participate in reminding caregivers about hand hygiene compliance. Hospitals post signs, put cards on bedside tables, adorn staff with bright buttons or pins and create video presentations. While the most effective methods for having patients remind providers about hand washing have not yet been studied, hospitals seem to be gravitating towards video format.

The Premier healthcare alliance partnered with the Centers for Disease Control and Cincinnati-based Catholic Health Partners in 2010 to show a video created by the CDC called Hand Hygiene Saves Lives. It's a five-minute production that shows a series of providers washing up and explaining the importance of hand hygiene. On-screen providers invite patients to help providers in infection control by reminding them to wash their hands or to use an alcohol-based sanitizer. For the study, CHP showed the video on a loop on its CCTV system and measured how often patients asked providers about hand hygiene.

Surveys of providers during the study period showed the suspected result: Patients didn't seem to have a problem with the idea of participating in hand hygiene, but when it came to actually asking the attending nurse or physician, most stayed silent. They seemed slightly more comfortable asking nurses to scrub up than physicians.

Surveys show consistently that patient reluctance is due to fear of provider backlash. This isn't necessarily a fear grounded in reality, and it may be that people feeling vulnerable need a lot of encouragement to do something that isn't yet considered a norm. Though they might not feel that way, patients are in the clear when it comes to asking providers about hand hygiene, at least at CHP. "Caregivers thought the initiative was great, and they didn't have issues with being asked," says Carolyn Wieging, RN, director of infection prevention at the health system. "If I forgot to wash my hands, I would hope a patient would remind me." Indeed, the health system liked the idea of the intervention enough that they still have the CDC's video in place.

Sue McArthur, director of infection prevention at Hartford-based Connecticut Children's Medical Center says her hospital trains providers in three vital behaviors to promote a receptive culture when it comes to hand hygiene reminders.

First, Connecticut Children's providers wash their hands every time they enter a room, no matter what they'll be doing there. This builds hand hygiene behavior so it becomes an ingrained habit. Second, providers maintain a mindset of 200 percent accountability. That is, they do the best they can to wash their hands every time they're supposed to do so. They ask everyone to help them remember. And if one provider forgets, another provider reminds him or her. The third behavior is simply saying thank you after receiving a hand hygiene reminder and remembering that it's not personal. According to Ms. McArthur, while most organizations focus only on the first behavior, it's adding behaviors two and three that really make hand hygiene compliance programs successful over time.

Ms. McArthur says the reminders are particularly important because they bring error rates down dramatically. "In hospital safety training, we learn that when a person is doing something very familiar, they make a mistake one out of every 1,000 attempts. If two people cross-check each other, the error rate goes down to one in a million," she says. Another important reason for providers to remind one another about hand hygiene is to show the behavior for the benefit of patients and families. "I do this for a living, and I sometimes feel uncomfortable asking a provider to wash his or her hands," she says. "If providers model that behavior, it makes it easier for patients and families to ask providers about hand hygiene."

Echoing Ms. McArthur, Ms. Pugliese suggests that even without numbers on infection control, involving patients in hand hygiene practices might be a good thing. "Patients might have great ideas, they might better understand what we're trying to do as providers, and their families might have interesting input," she says. She also thinks that making patients aware of provider hand hygiene might promote community hand hygiene in general after patients return home.

Providers at Kearney, Neb.-based Good Samaritan Hospital would agree. The hospital instituted Give Health a Hand, an award-winning community health hand-hygiene program, back in 2004, and since then it has placed an emphasis on involving patients with provider hand hygiene in the hospital. According to Marsha Wilkerson, director of marketing and communications at the hospital, Good Samaritan is proud of the way it has affected the culture of hand hygiene in the community through patient awareness.

Ms. Wilkerson also does see the recurring problem with patient reluctance, despite Good Samaritan's near-decade in working with patients in hand hygiene. "I think patients are uncomfortable asking healthcare providers to wash their hands, but constant reminders that they should ask increase their comfort levels. Good Samaritan also asks our caregivers to thank patients and to reinforce that asking is the right thing to do," she says.

Involving patients in hand hygiene serves an important function in keeping providers compliant. Ms. Wieging says that keeping hand hygiene compliance at the forefront of infection prevention efforts is important, as it's easy for providers to take it for granted and forget. Involving patients is one way to make sure forgetting is impossible for those who work with patients every day.

Finally, it appears that involving patients in hand hygiene, when successful, may have potentially beneficial effects for provider-patient relationships. After all, a successful campaign to involve patients as partners in hand hygiene is one that makes patients comfortable, holds providers accountable and uses diverse strategies to continually improve the ability to achieve a safety goal. Ms. Wilkerson provides the ultimate defense for involving patients in hand hygiene: Caregivers are only human. "It's a check and balance. Caregivers have the best intentions at heart, but you get busy, and you've washed your hands 18 times that day, and it's easy to make a mistake. When patients feel they can safely draw attention to that, it's good for everyone," Ms. Wilkerson adds.

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