When infection prevention staff observed hand hygiene habits about three years ago among fellow workers at Good Samaritan Hospital, Baltimore, they found less than 40 percent compliance with proper protocols. Today, that compliance rate has more than doubled in some units.
The improvement comes from an administration-backed hand hygiene project that includes staff education, patient empowerment and direct observation, says Kathleen Finch, R.N., C.I.C., director of infection prevention and control and occupational health consultant. To validate observations and rule out bias, the hospital enrolled in the McGuckin Methods International (MMI) hand hygiene program (www.hhreports.com), which measures the amount of hygiene products that should be used each month against how much actually was used.
Concurrent with the project, the hospital tracked multidrug-resistant organism cases from 2006 to 2008 and found that hospital-acquired cases of methicillin-resistant Staphylococcus aureus (MRSA) decreased 16 percent, vancomycin-resistant enterococcus went down 36 percent and Clostridium difficile decreased 37 percent. "We don't think it's just due to hand hygiene, but we think that plays a primary role," Finch says. Proper patient placement, isolation practices and environmental cleaning also contributed to the reduction.
Active hand hygiene compliance monitoring is now an expectation of the hospital's accreditation reviews and a state regulation for acute care, and the hand-hygiene project is part of hospital culture.
The most important factor in preventing the spread of pathogens and antibiotic resistance in health care settings is clean hands, according to the Centers for Disease Control and Prevention (CDC). It estimates that 1.7 million patients in the United States get infections in hospitals annually and about 99,000 of them die as a result.
Urinary tract infections account for 32 percent of these infections, surgical-site infections for 22 percent, lung infections for 15 percent and bloodstream infections for 14 percent, the CDC says. This costs hospitals in the United States up to $45 billion annually.
In late 2006, the infection prevention department at Good Samaritan Hospital began monitoring rates of hand hygiene compliance by observation to determine a baseline for compliance. "Our results showed about a 38 percent compliance rate for all units," Finch says. "So we knew we had to do some work."
A facilitywide action plan, Project IWASH, was created with the support of the hospital president. Hand hygiene education was conducted throughout the 346-bed hospital; hand hygiene screen savers, posters and other visual reminders were created and posted. Nursing and administrative leadership set a quality compliance goal for their units of 90 percent.
Next, managers chose about 40 hand hygiene observers to watch whether people washed or sanitized their hands before and after patient care; after contact with inanimate objects in a patient room; and before and after wearing gloves. Infection prevention provided monthly observation data to each unit, Finch says.
Positive reinforcement
To keep the project positive, observers issued "Thumbs Up" cards along with verbal thanks for doing their best to prevent infection or "Thumbs Down" cards, with an explanation on how to seize an opportunity in the future to prevent an infection. "We didn't want this to be a negative process," she says. Patients were brought into the mix by including information in admission handbooks encouraging patients to ask health care workers if they had washed their hands.
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EVER VIGILANT: Kathleen Finch, R.N., C.I.C., director of infection prevention at Good Samaritan Hospital, reviews proper hand-washing technique with a staff member. |
To rule out bias and validate direct observations, the hospital also began working with MMI, which issues monthly compliance reports for individual units. "Everybody wants to have good numbers, and it's easy to create good numbers if that's your goal," Finch says.
The first month with MMI, direct observers reported about 80 percent compliance, while MMI data reported 34 percent. "If hospitals are getting [observation] reports saying they are at 90 percent compliance and they're still getting infections, they need to do something," says Maryanne McGuckin, Sc.Ed.D., MT (ASCP), founder and president of MMI.
The problem with setting compliance goals is that everyone wants to reach them, McGuckin says. MMI compares the amount of hand hygiene product used in the various hospital units with patient bed hours and product usage benchmarks that it established through years of research and direct observation. The program is recognized by the CDC and the World Health Organization.
"In an ICU where there is a patient in a bed, hand hygiene should occur 144 times in a 24-hour period. We're counting the nurse, the radiologist, the person who takes blood—that's not a lot for an ICU patient, six times an hour," McGuckin says. "When it's a non-ICU patient, it should occur three times an hour, or 72 times a day; rehab and long-term care, 20 times daily; and pediatrics, 72 times."
For outpatients, hand hygiene should occur between three and six times per visit. MMI originally established six times for every ER visit, but it is collecting more data because the way ERs function can vary widely by hospital. MMI uses these benchmarks and the product and bed-hours data supplied by hospitals to calculate each unit's compliance.
"Product volume is a surrogate for observation. In product volume, we can tell you how many people are going to the sink and washing. We can't tell you how, where, when and why. For instance, we can't tell you if that wash was before or after patient contact," she says.
Hospitals can participate for $2,000 annually directly through MMI or at a reduced rate or for free if enrolling through one of three soap companies with which MMI has partnered—Ecolab Inc., GOJO Industries Inc. and Medline Industries Inc. Good Samaritan participates through Ecolab Inc., which is based in St. Paul, Minn.
By comparison, direct observation can cost hospitals between $6,600 and $36,600 per year in time spent and result in recording only 3 to 12 percent of all hand hygiene activity, McGuckin says. "Usually, about five to six months into the program we can get people to increase compliance by about 50 percent. Once you get out to a year, 18 months, we can get a lot of our sites at what we consider our 90th percentile," she says.
Good Samaritan learned with its first MMI report that the average hand hygiene compliance in three units was 34 percent, while direct observations in those units put compliance at 80 percent. At month six, direct observations were at 80 percent and MMI figures at 79 percent and at month 11 the gap between rates widened again to 94 percent and 69 percent, respectively.
The hospital has been successful in raising compliance because it involves patients, posts visible reminders throughout the hospital, holds in-service programs and has backing from administration. "The key thing is you have to get buy-in from administration and health care workers," McGuckin says.
The most important factor in getting patients to ask whether health care professionals have washed their hands is having a health care worker tell patients upon admission that they should do this.
The main reasons cited for noncompliance with hand hygiene are skin irritation, a belief that gloves take the place of hand washing and that people simply forget.
These days, Good Samaritan staff members want to discuss hand hygiene openly, Finch says. Hand hygiene training is part of hospital orientation; all staff revisits it quarterly and the hospital is standardizing the location of hand hygiene products. A master plan for product placement has been drafted, complete with maps, so that everyone will know exactly where to clean their hands on any floor in the hospital. "[Hand hygiene] seems to have taken on a life of its own," she says.
This article first appeared in the November 2009 issue of Materials Management in Health Care.
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