The Sound of Two Hands Washing: Improving Hand Hygiene

Hand washing. It’s a basic exercise in personal hygiene that most people learn as young children. Regularly washing one’s hands is widely promoted by everyone from mothers to infection control officers to the World Health Organization as an effective means of keeping germs and illness at bay.
Given this, one would expect health care providers to have the routine down pat AND to set the highest standard for compliance. Unfortunately, that’s not the case. Experts estimate that health practitioners comply with recommended hand hygiene procedures less than 50 percent of the time — contributing to some dire consequences. Nearly two million hospitalized patients in the US develop infections each year, and the most common transmitters of healthcare-associated pathogens are the contaminated hands of health care workers. Eighty thousand patients die from these infections each year.
Proper hand hygiene is the single most effective method to reduce these nosocomial, or hospital-borne, infections. The impact of effective hand hygiene can be seen in the chart below:
“There’s no question that hand hygiene must be practiced far more thoroughly and effectively,” says Donald Goldmann, MD, a Senior Vice President at the Institute for Healthcare Improvement (IHI). “People are in the habit of doing it poorly or sporadically, and we need to get them into the habit of doing it well and every time it’s indicated.”
Why is compliance with such a basic task so poor? There are a number of factors, say the experts. Sometimes it’s a lack of time or opportunity, such as during an extreme emergency. Other times it may be due to poor access to hand washing facilities, or avoidance due to skin irritations caused by frequent use of soap and water. Most often, though, it is the result of insufficient knowledge among personnel about the importance of good hand hygiene, lack of understanding of correct hand hygiene indications and technique, and/or lack of institutional commitment to promoting and supporting good hand hygiene.
It doesn’t help that existing guidelines for hand hygiene are more complicated than one might think, says Don Goldmann. “The guidelines from the Centers for Disease Control and Prevention, CDC, and others are exhaustive and rather complex,” he says. “It’s not surprising that people have a hard time following them.”
For example, Goldmann says, the guidelines urge health care workers to regard all surfaces in the vicinity of the patient as potentially contaminated and to practice hand hygiene accordingly. But does that mean they should wash after they touch any potentially contaminated objects and surfaces in a patient’s room? (Yes, says Goldmann.)  There are rules about washing in the midst of a single encounter with a patient if, for instance, the clinician touches a contaminated or potentially contaminated part of the patient’s body and then moves his or her hands to a “clean” part of the body (such as an intravenous catheter site).
Other rules spell out when it’s necessary to wear sterile gloves (when inserting a catheter, for example, and even then, hands should be washed before donning gloves), when to use antimicrobial soap and water (when hands are visibly soiled or have been exposed to bodily fluids) and when to use an alcohol-based gel or rub (for routine decontamination of hands after most patient contact, but not after contact with a patient who has antibiotic-associated colitis due to Clostridium difficile).
Studies also now show that waterless, alcohol-based gels, liquids, or foams are generally more effective in reducing the number of viable bacteria and viruses on hands than traditional soap-and-water washing. An added incentive to use the hand rubs is that they take less time, and, because they contain emollients, produce less hand irritation and dryness than repeated use of soap and water.   
Helpful Tools
To help clarify the guidelines and provide organizations with a roadmap toward improved compliance with good hand hygiene practices, IHI collaborated with the Division of Healthcare Quality Promotion of CDC, the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society of Healthcare Epidemiology of America (SHEA) to develop a toolkit for hospitals and health care workers called “How-to Guide: Improving Hand Hygiene.”
The toolkit says there are four critical components to a successful, multidimensional hand hygiene program:
  • Clinical staff must understand the key elements of good practice;
  • They must demonstrate competence at following good practices;
  • Alcohol-based rubs and gloves must be readily available at the point of care; and
  • Competency and compliance must be routinely monitored and that feedback is provided to staff.
The last element — routinely monitoring compliance and competency — can be particularly challenging. But a new quality improvement tool is showing promise.
Random auditing in the health care setting was developed by two Burlington, Vermont-based organizations: the Center for Patient Safety in Neonatal Intensive Care, and the Vermont Oxford Network, a voluntary collaboration of health care professionals from throughout the nation focused on improving care for newborns. Neonatologist Robert Ursprung, MD, led the effort; IHI’s Don Goldmann was among his colleagues. Ursprung serves as Associate Director of Quality Improvement for the Pediatrix Medical Group, an 800-physician group headquartered in Sunrise, Florida. He practices at Cook Children’s Medical Center in Ft. Worth, Texas.
“Random auditing is a non-burdensome way to collect data and create run charts,” says Ursprung. Designed to assess the progress of any safety improvement, it can easily be applied to hand hygiene. It’s also a notion that’s been successfully practiced in banking and pharmaceutical manufacturing. The concept is simple: If there are ten key processes that must be managed according to strict guidelines in order to maximize quality and safety, a random audit of, say, one process each day will be just as effective at improving compliance as a daily audit of all ten processes — at a much lower cost.
To adapt this model for health care, Ursprung and his colleagues developed an innovative and customizable tool: a “deck of cards,” with a question on each card. The improvement team creates a question for each card, tailoring them to the specific project, culture and issues being audited. 
For example, Ursprung says questions related to hand hygiene might include these:
  • Does this patient’s bedside have an alcohol hand rub dispenser “easily accessible,” that delivers product properly? 
  • Is this antimicrobial soap dispenser delivering product properly (i.e., it is not empty or clogged, and one “pump” or “squirt” delivers sufficient product for hand hygiene). 
  • Are there gloves of various sizes (i.e., small, medium and large) “easily accessible” from this patient’s bedside? 
  • Is lotion “easily accessible” by this patient’s bedside and is it functioning properly? (Skin irritation is a major deterrent to proper hand hygiene; the CDC recommends that lotion be made available by the hospital.)
  • Is this sink working properly, with water temperature that is not “too hot”?
  • Is this paper towel dispenser functioning properly (i.e., not empty or malfunctioning)?
  • Are there hand hygiene “reminders” (i.e., posters, flyers, stickers) visible in the area?
  • Does this staff member know the most recent hand hygiene compliance rate specific to their role (i.e., nursing, respiratory therapist, NNP, physician) in the unit?
  • Are any unit clinical staff wearing artificial nails? (Artificial nails are more likely to harbor pathogens.)
  • Was there feedback of the unit’s most recent hand hygiene compliance rates to unit staff (i.e., a poster displayed in a break-room, an email, discussion at staff meetings, other)?
A designated auditor chooses a card at random, and the question on the card determines that audit’s focus. The scope of the audit — whether the assessment covers every patient and every relevant item on a unit, or a designated subset — is also determined before the audit begins. The card has a user-friendly data recording tool — a simple yes/no checkbox for each bedside or patient encounter.
Dr. Ursprung says that random auditing has been very effective at improving hand hygiene compliance in the two 50-bed units in which he practices. “We identified that product availability was a weakness,” he says, “and that wasn’t on our radar screen before we audited. We also learned there was a lack of understanding about what proper hand hygiene really entails. So we did some targeted education, shared data from the audits, and encouraged staff to hold each other accountable.”
Ursprung also says the value of auditing lies not just in the findings, but in the act itself. “My impression is that when auditing stops, compliance goes down. So we’ll keep doing it,” Ultimately the goal is to ingrain habits so that auditing can be done less frequently without affecting compliance. 
Improving and maintaining effective hand hygiene habits requires a combination of assessment, education, and ongoing monitoring. Creativity doesn’t hurt, either, as demonstrated by the following examples of institutions that have successfully improved hand hygiene.
University of Pittsburgh Medical Center, Shadyside Campus
At the University of Pittsburgh Medical Center (UPMC), Shadyside Campus in Pittsburgh, Pennsylvania, “Clinicians are expected to wash their hands every time they enter a patient’s room, and again before they leave, every time,” says Barbara Hildebrand, RN, MBA, CIC, Clinical Resource Coordinator with UPMC’s Center for Quality Improvement and Innovation. “Our hand hygiene goal is ‘In and Out, No Matter What,’” she says. It’s a high standard but necessary.
Before the launch of the hospital’s improvement effort, compliance on two pilot units with the high standard of washing both before AND after seeing a patient was just 17 percent. “In most hospitals, if you ask people if hand hygiene is important, they will say yes,” says Robert Ursprung. “If you ask if they wash, they will say of course. But when you begin to audit, you commonly find that pre-patient contact hand hygiene is good, but post-patient contact it is quite poor.” Units trying to improve hand hygiene without audit data will find it difficult to know where to target resources or education efforts.
Launched at the end of 2005, Shadyside’s highly visible campaign, the Joseph Hardik Hand Hygiene Project, honors the memory of a former patient.
“During Mr. Hardik’s stay his family observed that health care workers often came in and out of his room without washing their hands,” says Barb Hildebrand. “It concerned them, and we used their observations as a learning opportunity. Naming this program after him helps to personalize this initiative for our staff.”
With support from The Robert Wood Johnson Foundation, the Hardik initiative is designed to remind everyone from clinicians to housekeeping staff to patients themselves about the importance of hand hygiene, and includes an educational component as well as ongoing assessment and tracking through observation and measuring consumption of hand washing products.
“We had been doing hand hygiene audits for years,” says Hildebrand, “but when we got the grant to launch this program we decided to focus more intensive efforts on two pilot units. We started with a staff survey to determine their baseline understanding about hand hygiene.”
The hospital team assembled to lead the program included representatives from nursing management, clinical education, housekeeping and facilities. A nursing student was trained as an “undercover” observer, watching workers come and go from patient rooms and noting their hand washing habits. This data helped establish a baseline rate of compliance and continues to provide a measure of the campaign’s progress.
The team surveyed the availability and locations of hand sanitizers that dispense alcohol-based gel, and arranged for installation of additional dispensers in locations that lacked them. In addition, counters were installed in all dispensers that measure the number of times gel is used. 
With baseline data gathered, the team launched a comprehensive education and promotional campaign that included group presentations as well as written information for hospital staff and patients about the importance and the proper techniques of hand washing. The team is currently developing a mandatory web-based education module for staff that will be available on the hospital’s intranet.
Getting nurse managers on each unit to serve as hand washing champions, observing staff and reinforcing the message about the importance of good hand hygiene, is also a key element of the program, says Hildebrand.
To provide a prominently located visual reminder, the team designed a new hand washing logo and had it printed on the front of patient gowns.
The gowns were tested on three units, says Doug Kassab, Director of Clinical Support for three of UPMC’s hospitals, including Shadyside, and chair of the linen utilization team. “We also took the opportunity to improve the whole gown, and we are now in the process of converting to the new gowns with the hand washing reminders at all 17 hospitals in the UPMC system,” says Kassab. “The more non-verbal reminders we can put out there, the better.”
The gown is a good way to involve patients and families in the support of good hand hygiene, says Sue Martin, MSN, who works in UPMC’s Center for Quality Improvement and Innovation. “We know that staff will eventually get to the point where they don’t even notice the logo on the gowns,” she says. “But for each new patient it will be new, and we want to capitalize on that.”
To that end, Barb Hildebrand says she and her team are in the process of creating a Patient and Family Hand Hygiene Participation Guide that will include information about the importance of hand washing as well as the importance of reminding visitors and clinicians to wash. “We tell them it’s okay to say, ‘Before you touch me, can you please wash your hands?’” says Hildebrand.
The patient packet will also include a mail-in survey and “reinforcement cards” that patients or family members can hand to clinicians. “These are little cards that either compliment them on their hand washing, or point out that they missed an opportunity to wash their hands,” she says. “The cards look the same on the front, so they’re not meant to draw attention in a punitive way, but simply to reinforce our goals.” Hildebrand says she already hands the cards out herself from time to time, and staff seem grateful either way.
After four months of the improvement effort, compliance had risen to 60 percent, enough of an improvement to warrant spreading the initiative house-wide, beginning in the fall of 2006. Staff continue to work toward 100 percent compliance on the pilot units and eventually throughout the hospital. “It’s hard to change habits, and it takes time,” says Hildebrand. “But we are looking at lots of ways to get our compliance up, and we will keep at it, and we will get there.”
Parkview Hospital NICU, Ft. Wayne, Indiana
In the Neonatal Intensive Care Unit (NICU) at Parkview Hospital in Ft. Wayne, Indiana, a member of the Vermont Oxford Network, staff believe that careful attention to hand hygiene has contributed to a low rate of hospital-borne infections. “We have had one of the lowest infection rates in the Network for years,” says Suzanna Johnson, RN, NICU staff nurse. The 2005 rate of nosocomial infection in the 30-bed NICU was 0.2 per 100 patient days, down from 0.3 in 2004. “We have very strict hand washing protocols, and we are very good about observing them. Hand washing protects everything we do,” says Johnson.
Johnson says the unit’s consistently good hand hygiene habits are the legacy of its long-time medical director, William Lewis, MD, who recently stepped down. “Dr. Lewis is very big on hand hygiene,” she says. The strategy he promoted, says Johnson, was based on creating a “visual square” around each bed or bassinet. “We create a six-by-six foot square around each baby, and anything that goes in or out of that square has to be cleaned or not re-used,” she explains. As a result, tools like thermometers, calculators, and the baby’s chart stay at each bedside.
In addition to following established CDC guidelines for good hand hygiene, Johnson says the staff has developed additional habits based simply on common sense. “We don’t pick anything up off the floor,” she says. “If something drops, we leave it on the floor until we are finished caring for that baby, and then we dispose of it.”
Before entering the unit everyone from clinical staff to family members scrubs their hands with soap and water. “Family members get so used to this routine, they let us know when they see someone not doing it,” says Johnson. There is also an alcohol-based foam dispenser at each bedside, says Johnson, and parents are taught when to use the foam and when to wash with soap and water.
Johnson says all NICU staff are highly focused on keeping their infection rate low, and that entails making sure other hospital staff adhere to strict rules when they visit the unit. “If a baby needs an x-ray, the tech has to scrub before entering the unit,” says Johnson. But that’s not all. “The film plate goes into a clean pillowcase, and we position the baby for them. They don’t touch the baby.”
NICU staff help each other comply with protocols, and no one takes offense at being reminded, says Johnson. Regular audits by outside observers assess their compliance with good hand hygiene practices, and different staff members are periodically assigned to observe and report on their observations.
Johnson says a recent slight increase in the unit’s infection rate has been a reminder that constant vigilance is essential. Staff are working to identify potential causes for the increase and make appropriate adjustments to processes and procedures. “We are always learning how to be even more careful,” says Johnson.
Providence Hospital NICU, Anchorage, Alaska  
One of the keys to improving hand hygiene is changing the long-held perception that infections are inevitable, says Deb Sims, RNC. Sims is supervisor of the 38-bed Level 2 and 3 NICU at Providence Hospital in Anchorage, Alaska, another Vermont Oxford Network member. “Babies get infections, you give them antibiotics and move on,” she says, describing the old way of thinking. “But we have changed our culture so that it’s no longer okay when a baby gets an infection.”
That attitude is one factor behind the drop in the rate of sepsis infections in the NICU from 3.0 per 1,000 patient days in 2003 to 1.1 per 1,000 patient days in 2005, and zero through the first quarter of 2006. This decrease is undoubtedly due to a number of factors that are key to reducing sepsis, one of which is proper hand hygiene. The rate of compliance with hand hygiene standards in the NICU rose from 90 percent in early 2005 to 100 percent for six out of the last nine months of that year. 
Sims says the unit’s focus on improving hand hygiene was part of a larger hospital-wide infection control effort. Sims gathered NICU compliance data through random unannounced observation, and posted it along with the unit’s infection rates at the scrub sink for everyone to see. “We were posting the number of days the unit was sepsis-free,” says Sims, “and when you get over 100 days, you can feel the culture shift. Now there is an audible groan when an infection occurs.”
In addition to posting aggregate results of the observational audits, Sims says in the beginning of the push to improve hand hygiene she sent individual results to each clinician, including physicians. “Compliance improved, and now we no longer collect individual results,” she says.
With alcohol gel dispensers by every bed, Sims says it was relatively easy to teach parents good hand hygiene skills. “Parents are great, they are totally compliant once they know the rules,” she says.
Sims says that data about the unit’s improved performance has been a very effective motivator. “If you can show people that their efforts are paying off in reduced infection, it’s all the motivation they need,” she says.
HealthEast Care System, St. Paul, Minnesota
HealthEast Care System has improved compliance with hand hygiene guidelines from 36 percent to more than 70 percent in a 20-bed medical/surgical ICU, an effort that has now spread to all ICUs in this three-hospital system, as well as to a long-term acute care facility in the network. The gains are the result of a program called CHAMPS — Clean Hands Are Making Patients Safer — a highly visible campaign designed to both educate and remind staff about the importance of proper hand hygiene. 
The improvement team leading the effort developed a CHAMPS logo, which was used on everything from posters to golf towels given as recognition awards for hand hygiene “champs.” Screen savers, Post-It notes (saying “If You Touch This, Clean Your Hands,”)  and a hand hygiene patient/visitor brochure were also created, along with a message on each patient’s white board saying, “It’s OK to Ask.”
Physician champions as well as staff champions on each unit spearheaded the effort at the local level, and helped organize targeted training with newly developed learning packets based on the CDC guidelines. Computer modules were also developed as teaching tools.
Environmental assessments helped identify the need for more accessible hand hygiene products, as well as the need to replace some older sinks in the long-term acute care facility that were poorly designed and in some cases leaking, causing people to avoid using them.
As awareness increased, so did the number of ideas, says Boyd Wilson, MS, CIC, System Director, Infection Control and Epidemiology. “We had some physicians come forward and say they would probably use hand sanitizing gel more often if we put a dispenser next to where they do their dictation.” This visual reminder has helped promote better hand hygiene after patient visits, says Wilson.
 “The challenge is trying to keep the campaign fresh,” says Boyd Wilson, MS, CIC, System Director, Infection Control and Epidemiology. The theme of the awareness campaign changes monthly, he says, and sometimes the stranger it is the more staff pay attention to it. “During the Minnesota State Fair month, where you can get every conceivable food on a stick, we had posters with hand-sanitizer on a stick. It was goofy, but it was noticeable.” Questions of the week, games with prizes, and fact/fiction handouts also help get and keep people’s attention focused on the issue. 
Perhaps most important, Wilson says compliance data is fed back regularly to each unit and to the administration, in the form of a quarterly report. This helps motivate people to improve. Compliance climbed steadily, from a mean of 33.6 percent compliance (pre- and post-patient contact, combined) to 69.9 percent in the first six months of the campaign.
The Goal: Perfection
IHI’s Don Goldmann applauds efforts such as these, and says they demonstrate that dramatic improvement in hand hygiene is possible when an organization or even an individual commits to it. He also is encouraged by the growing number of hospitals that are paying closer attention to this issue and working to improve. “I am optimistic that proper hand hygiene will become so embedded in our health care system that nobody will even think of not doing it right,” he says.
But in order to get there, everyone who works with or around patients must take personal responsibility for good hand hygiene, he says. In an article published in the July 13, 2006 issue of The New England Journal of Medicine, Goldmann writes that making systemic changes to support good hand hygiene — educating workers and patients, verifying and reinforcing their competence, and making appropriate products and facilities accessible — is only part of the solution. Personal accountability, Goldmann argues, should not be forgotten.
“True, the hospital and its leaders are accountable forestablishing a system in which caregivers have the knowledge, competence, time, and tools to practice perfect hygiene,” he writes. “But each caregiver has the duty to perform hand hygiene — perfectly and every time. If every caregiver would reliably practice simple hand hygiene when leaving the bedside of every patient and before touching the next patient, there would be an immediate and profound reduction in the spread of resistant bacteria.”
At Greenview Regional Hospital and the Medical Center, two hospitals in Bowling Green, Kentucky, the policies and programs addressing hand hygiene compliance emphasize personal responsibility, to apparent good effect.
According to reports presented at a recent meeting of the Society for Healthcare Epidemiology of America and written up in an April 5, 2006 Wall Street Journal article titled “Hospitals Get Aggressive About Hand Washing,” compliance rates at the two hospitals were in the single digits in some units.
Leaders there decided to create a comprehensive educational program for staff, particularly targeting those who were identified through an auditing process as regular offenders of good hand hygiene practices. Those who failed to follow guidelines were subject to escalating remedial actions, from a simple reminder, to required completion of an educational module, to meeting with the department chair, disciplinary action, or review by the credentialing committee.
“This program stresses personal responsibility,” says Goldmann, which, along with appropriate tools for assessment, education, and ongoing monitoring, could be an essential element in promoting better hand hygiene. 
At the Bowling Green hospitals, the combination of elements has been remarkably effective: Compliance rates improved to 85 percent for health-care workers overall and 95 percent for physicians alone last year at Greenview Regional, and close to 100 percent for all staff at the Medical Center.​
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