It’s been a while since we did our last column on hand hygiene (see our January 5, 2010 Patient Safety Tip of the Week “How’s Your Hand Hygiene?”). The New England Journal of Medicine recently put out a hand hygiene video. It’s actually quite good, being thorough, accurate, and professionally done. But remember our mantra “Stories – Not Statistics”. There are certain types of presentation that are much more memorable than others. We came across two other videos on hand hygiene that are more likely to have a lasting impact on your staff (and patients).
One that sends a very powerful message was just put out by the US Department of Health and Human services. “Healthcare-Associated Infections are Serious” is a video that is part of the HHS Partnering to Heal toolkit. This is a particularly good video to play for your staff because it shows a staged root cause analysis on a young patient who dies from a hospital-acquired infection after admission for a usually benign condition. It tells a compelling story that every healthcare worker can empathize with and realize it could happen in their facilities.
But our favorite video on HAI’s and hand washing is the one done by the Penn State Hershey Medical Center Infection Control Team. This also sends a powerful message that is likely to be remembered. Its semi-animated format also introduces a bit of levity that makes this one an ideal video to be shown to patients and families as well. We have found that the majority of patients remain very reluctant to challenge their physicians or other staff on hand washing. But if you give them an opportunity to do so in a less contentious manner they are more likely to ask staff about hand hygiene. If they can laugh a bit and say “Doctor, that funny video said you are supposed to wash your hands first!” they are more likely to speak up and really get the physician to wash his/her hands. So we recommend you consider integrating this video into your patient education program on admission (you can run it on an iPad or similar device) or, if you integrate messaging with your TV system, run it periodically on the TV.
In our January 5, 2010 Patient Safety Tip of the Week “How’s Your Hand Hygiene?” you may remember we put on the table the concept of the “Wanted” poster. That might be an old-West style poster of their attending physician dressed in cowboy attire with the caption “BEWARE!...Armed and Dangerous…If you see this doctor, make sure he washes his hands!”. Then the patient could simply point to the poster and hopefully he and his physician will chuckle as the physician washes his/her hands. We haven’t yet found any takers on this idea. So if you try it, let us know how it worked!
In that prior column we also mentioned the ongoing Joint Commission Center for Transforming Healthcare Hand Hygiene Project. They have since published the best practices emerging from that project. That project also served as the basis for their free web-based tool, the Targeted Solutions Tool™, for hand hygiene projects in which many of you are participating.
The 8 hospitals participating in the original project used a Six Sigma methodology to address improving compliance with hand hygiene. Their list of root causes for failure to clean hands included the following:
For each of the causes listed above the organizations developed potential solutions, piloted them, and measured impact. Sometimes the solutions were simple, like standardizing where the dispensers were located and making sure they were always filled. Most located them near the doorways to the patient rooms but others included putting them in high-traffic hallways or near high-touch objects. We liked the suggestion of painting the background so they stood out against the background.
But looking at workflows and re-engineering them was very important. One hospital calculated that nurses would have to wash their hands over 200 times a shift. So redesign of workflow to minimize the number of times a nurse would have to go in and out of a patient’s room was critical. Ensuring needed supplies were in the room reduced the amount of movements. (Note that such workflow redesign may have the added benefit of reducing interruptions.) One hospital “double teamed” the respiratory therapists drawing blood gases. Another reengineered the way food service workers delivered and picked up trays.
Gloves remain a big issue. The perception that you don’t have to wash your hands if you are wearing gloves remains pervasive.
While most started with “secret shoppers” to monitor compliance with hand hygiene and some used soap/sanitizer gel utilization rates as a proxy for hand washing, half used new technologies such as infrared badges to monitor hand washing by staff. You may have seen some of those technologies highlighted recently in the New York Times (Rosenberg 2011). Displaying compliance charts and providing feedback was critical. Many hospitals also provided immediate coaching when they saw problems with hand compliance (the coaching was delivered by someone other than the “secret shopper”).
But there is another constituency frequently ignored – visitors. A healthcare worker recently told us about her own experience as a patient. She said her physicians and nurses were pretty good about washing their hands…but her friends and relatives came and went without any understanding about hand hygiene. A couple hospitals in the project did engage families in their initiatives. They did it primarily to have families also be vigilant about staff washing their hands but they noticed that the families also mimicked that behavior.
But perhaps most important of all is that basic premise we keep returning to – a culture of safety. Culture trumps policy every time. Bob Wachter points out in many of his talks that we will suspend doctors from our medical staffs for delinquent medical records but yet we let them get away with not washing their hands all the time. Compliance with hand hygiene has to be something that everyone buys into – starting with your clinical and administrative leaders – and makes a priority in your organization.
Overall, the 8 hospitals in the Hand Hygiene Project improved their hand hygiene compliance rates to over 80% and most improved their rate of healthcare-associated infections (though the report did not detail the latter).
Note: There also are a variety of good video resources on hand hygiene available at the APIC website, some very serious and others a bit lighter and humorous.
Longtin Y, Sax H, Allegranzi B. et al. Hand Hygiene. N Engl J Med 2011; 364 :e24 March 31, 2011
US Department of Health and Human Services. “Healthcare-Associated Infections are Serious” video
Penn State Hershey Medical Center Infection Control Team/McGuckinMethodsIntl.
Healthcare Worker Hand Hygiene Educational Training Video.
Joint Commission Center for Transforming Healthcare, American Hospital Association, Health Research and Educationsl Trust. Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project. November 2010
Joint Commission Center for Transforming Healthcare. Targeted Solutions Tool™.
Rosenberg T. Better Hand-Washing Through Technology. The New York Times. April 25, 2011
APIC. Videos and other resources on hand hygiene.