An observational study (Burcharth
2014 as reported by Bernard
2015) found that an astonishing 20% of attendees at an American surgical
conference failed to wash their hands after visiting the restroom!
Admittedly, that may not be the same as hand hygiene in
surgeons prior to surgery or prior to and after examining patients elsewhere.
But we’ll bet that some of the same factors that influence hand hygiene apply
in both situations. Four timely studies on the factors that influence the hand
hygiene compliance of physicians and others lend some insight.
In the first, Squires and colleagues (Squires
2014) did semi-structured interviews with medical and surgical physicians
and residents at a Canadian tertiary care center with two campuses, chosen via
a quasi-experimental sampling strategy. They found 53 specific beliefs from 9
theoretical domains that influenced hand hygiene practices of participants.
Sounds too ethereal for us! But the many statements from physicians they quote
provide great insight.
They did find some key barriers and enablers found in
previous studies: environmental context, social pressure, perception of the
risk of cross-contamination, and a positive attitude about hand hygiene itself.
But they also identified knowledge gaps about hand hygiene guidelines and evidence
linking poor hand hygiene to healthcare-associated infections. Moreover, they
identified a skill gap in the performance of hand hygiene.
Unlike studies in nurses, which show nurses tend to perform
hand hygiene as a routine and automatic process, their study found that physicians required a conscious decision
to perform hand hygiene and that cues,
visual or otherwise, were often needed to encourage hand hygiene.
Social influences can come from colleagues and patients,
though evidence for the influence of patients was weaker. They stress the
importance of role models and
“positive deviance” in encouraging hand hygiene. At least one of the
respondents described a phenomenon we’ve often spoken about: if you see the
leader of a team of rounding physicians and students stop to wash his/her
hands, the rest of the team members are very likely to do the same.
(We’re not surprised about the relative lack of influence by
patients. Patients still seldom speak up despite our efforts to get them to do
so. They may be reluctant to potentially offend their physician. We’ve
recommended trying a little humor to help patients feel more comfortable
“challenging” their physician: use “Wanted…Armed and Dangerous!” posters in
patient rooms, putting a picture of their attending physician on an old-west
style wanted poster with a subcaption “If you see
this individual, beware and make sure he/she washes his/her hands!”. But before
you try that one, make sure your attending physicians also have a sense of
humor!)
System constraints, as expected, were significant
influences. Having easy access to hand
hygiene resources at the point of patient contact was an almost universally
mentioned factor. But they also found that high workloads were a barrier to hand hygiene.
They did find some
differences across specialties. Fewer surgery than medicine physicians
reported that other physicians influenced their hand hygiene practice. They
speculate that, while this might reflect a sample size artifact, it could
reflect that surgeons tend to work more independently than medicine physicians,
who tend to work more in teams.
The Squires study lays the groundwork for further research
and development of strategies to improve hand hygiene rates among physicians.
It also has an extensive bibliography that you may find useful.
The second study (Chassin
2015) reports lessons learned from the Joint
Commission Center for Transforming Healthcare hand hygiene quality improvement
project. The eight hospitals in that project used Lean, Six Sigma and
change management methods and saw a 70.5% increase in compliance (from 47.5% to
81.0%). This study included multiple types of healthcare workers, not just
physicians.
They initially identified 41 different causes of hand
hygiene noncompliance and condensed these into 24 groups of causes. But key
causes varied greatly among the hospitals so each hospital focused on those
issues most important at their facilities and organizations.
There is much overlap with barriers identified by Squires and
colleagues and other previous researchers. Systems
issues are common (hand hygiene facilities not readily available, empty
hand dispensers, no soap at the sink, broken dispensers, etc.). But other
system issues may include lack of space to free up hands for washing, need to
go in and out of rooms frequently for supplies, etc. There are also occasional
healthcare workers for whom the hand cleaning product may be irritating or
otherwise unpleasant.
Workflow issues
may also be barriers and the impression (perceived or real) that hand washing
will slow you down is a frequent barrier.
But, much like described in the Squires study, people often simply forget to wash or are
distracted and staff fail to remind
each other about hand hygiene. Education is often inadequate. Many still
have the mistaken impression that
there is no need for hand hygiene of they are wearing gloves. Most importantly, the safety
culture (or lack thereof) of the organization is an overriding factor. In
many columns of our columns we’ve discussed how safety culture may vary
considerably by unit (that’s why improvement projects work best when using the
CUSP or comprehensive unit-based safety program model). So even though hand
hygiene must be an organization-wide priority you may need to tailor your
individual interventions to specific units.
Recommendations (from the Chassin
paper and the project website) were nicely summarized into the “HANDS” acronym:
H Habit
A Active feedback
N No one excused
D Data-driven
S Systems
Making handwashing a habit and automatic is key. Healthcare workers should always wash in and wash
out upon entering/exiting a patient care area and before and after patient care.
In addition to providing education, training, and visible
and technology-based reminders, one of the most important methods for active feedback was use of “just-in-time” coaching. These
individuals, upon observing an episode of noncompliance with hand hygiene,
would immediately discuss with the “offender” and find out the reason(s) why
they did not perform hand hygiene. Discipline-specific training and education
may be important for some issues, such as glove-related problems. And when you
use visible and technology-based reminders, make sure you rotate them so that
they remain effective and don’t simply get lost in the background “noise”.
“No one excused” means no
one is excused. We all know that physicians generally have much poorer
compliance with hand hygiene than nurses and other healthcare workers. It is
incumbent upon the hospital and physician leadership to make hand hygiene a
priority. That holding everyone accountable and responsible and applying
progressive discipline from the top. It emphasizes the importance of role
models. As we noted above, if you see the leader of a team of rounding
physicians and students stop to wash his/her hands, the rest of the team
members almost always do the same.
Being data-driven
means that you use an acceptable, accurate monitoring and measurement system
and provide the data in as near real-time as possible. It also means you
scrutinize the data and act upon it.
Fixing the systems,
not just the people, is critical. That means providing easy access to hand
hygiene equipment and supplies at places the healthcare workers need them. It
also means keeping hand dispensers filled. But it is more than that. One of the
barriers often noted is that the healthcare worker has his/her hands full and
no place to put things down so they can wash their hands. So it means making
sure space is available to put those things down. You should also re-engineer
the space to minimize the number of times you need to exit and re-enter a room
(eg. keep frequently needed supplies in the room so
you don’t have to go out and come back in). They also note that your alarm
management initiatives (see our July 2, 2013 Patient Safety Tip of the Week “Issues
in Alarm Management” and our multiple other columns on alarm-related
issues) should reduce the frequency of false alarms that cause your staff to
needlessly exit the room. Also, improving the systems by using new technologies
like radiofrequency identification and automated reminders and real-time
scoring is promising. And placing glove dispensers near the hand dispensers may
be important in dealing with the glove-related issues.
The underlying theme of the Chassin
paper is that using the Lean, Six Sigma or similar approach allowed each
hospital to customize its
improvement efforts by focusing on the causes most prevalent at its own
facility. “One-size-fits-all” strategies probably won’t work very well.
A third study did qualitative interviews with senior
hospital staff at an Australian academic medical center (McInnes 2014). Seven
themes emerged: culture change starts
with leaders, refresh and renew the message, connect the five moments to the
whole patient journey, actionable audit results, empower patients, reconceptualising non-compliance and start using the hammer. Like all
other studies they note the importance of leadership
not just verbally endorsing good hand hygiene practices but actually
demonstrating their commitment and serving as role models. They speak about the hospital hierarchy, whether official
or not, that leads to staff not speaking up when they see examples of
noncompliance with hand hygiene. They discuss the need to train staff in ways
to tactfully address the issue with noncompliers,
including use of “graded assertiveness”. Refreshing
the message, as noted by many others, is a strategy taken from the advertising
and marketing industry. Just like advertising posters get changed at the local
bus stop, hospital posters etc. need to be refreshed so that people notice
them. They then note that WHO’s “5 Moments of Hand Hygiene” don’t all apply to
all settings in the hospital. So there is a need to tailor strategies to individual settings. For example, they
note that a group rehabilitation setting is much different than an inpatient
bedside setting. Audits need to be
actionable. All too often they are neither timely nor specific enough for
actions. They recommend deaggregating data so that
managers and department heads can take actions with specific groups or
individuals. They discuss barriers to empowering
patients and the multiple reasons patients won’t speak up. However, they
also stress the need to educate staff and physicians on how to respond when a
patient does speak up. The last 2 themes, reconceptualising
non-compliance and start using
the hammer, are related.
Many of those interviewed felt that hand hygiene noncompliance needs to be treated as an error
and that those making such errors need to be held accountable. Using a graded/staged or tiered approach to
managing noncompliant staff (eg. progressive
discipline) was felt to be the best approach. Yet many felt that such an
approach was counter to the “no blame” culture and also could aggravate a
shortage of staff and physicians. All agreed that a multimodal approach to behavior change is much more efficacious
than single interventions.
And the fourth study comes from the Pennsylvania Patient
Safety Authority (Bradley
2014). Examples of events related to hand hygiene compliance are provided
and there are good summaries of the efficacy of alcohol-based handrubs and currently available methods of monitoring
compliance. Then the author discusses components of a multimodal approach that begins with assessing barriers to hand hygiene and surveying hand hygiene beliefs
and behaviors. It provides links to several useful online tools for those
assessments, such as the WHO Hand Hygiene
Self-Assessment Framework 2010 and the WHO
Perception Survey for Health Care Workers. It goes on to suggest
implementation of a hand hygiene “bundle”
and map specific strategies to
barriers, beliefs and behaviors found in the assessments and suggests a graduated intervention scale called the “disruptive
behavior pyramid” as a measure to curtail reckless hand hygiene behaviors.
These 4 studies should help you in addressing this
long-running problem that continues to plague most hospitals. Also, for those
of you who may have missed them in the fall of 2014 there were evidence-based
updates on “Strategies to Prevent Healthcare-Associated Infections through Hand
Hygiene” (Ellingson 2014)
and SHEA’s “A Compendium of Strategies to Prevent Healthcare-associated
Infections in Acute care Hospitals: 2014 Updates” (SHEA 2014).
Some of our other
columns on handwashing:
January 5, 2010
“How’s
Your Hand Hygiene?”
December 28, 2010 “HAI’s:
Looking In All The Wrong Places”
May 24, 2011 “Hand
Hygiene Resources”
October 2011 “Another
Unintended Consequence of Hand Hygiene Device?”
March 2012 “Smile…You’re
on Candid Camera”
August 2012 “Anesthesiology
and Surgical Infections”
October 2013 “HAI’s:
Costs, WHO Hand Hygiene, etc.”
November 18, 2014 “Handwashing
Fades at End of Shift, ?Smartwatch to the Rescue”
References:
Burcharth J, Pommergaard
H-C, Alamili M, et al. Fra det
videnskabelige julenummer: Hver femte kirurg
vasker ikke hænder efter toiletbesøg
– et etnografisk feltstudie.
Ugeskr Læger 2014; 176:
V66434
Bernard D. Twenty Percent of Surgeons Didn't Wash Their
Hands in Bathroom. Outpatient Surgery Magazine. January 6, 2015
Squires JE, Linklater S, Grimshaw
JM, et al. Understanding Practice: Factors That Influence Physician Hand
Hygiene Compliance. Infect Control Hosp Epidemiol 2014; 35(12): 1511-1520
Joint Commission Center for Transforming Healthcare. Hand
Hygiene Project.
http://www.centerfortransforminghealthcare.org/projects/detail.aspx?Project=3
Chassin MR, Mayer C, Nether K. Improving
Hand Hygiene at Eight Hospitals in the United States by Targeting Specific
Causes of Noncompliance. Joint Commission Journal on Quality and Patient Safety
2015; 41(1): 4-12
http://www.ingentaconnect.com/content/jcaho/jcjqs/2015/00000041/00000001/art00002
McInnes E, Phillips R, Middleton
S, Gould D. A Qualitative Study of Senior Hospital Managers' Views on Current
and Innovative Strategies to Improve Hand Hygiene. BMC Infect Dis 2014; 14
(611)
http://www.biomedcentral.com/1471-2334/14/611
Bradley S. A Systems and Behavioral Approach to Improve Hand
Hygiene Practice. Pa Patient Saf Advis
2014; 11(4): 163-7
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2014/Dec;11%284%29/Pages/163.aspx
WHO Hand Hygiene Self-Assessment Framework 2010
http://www.who.int/gpsc/country_work/hhsa_framework.pdf
WHO Perception Survey for Health Care Workers
http://www.who.int/gpsc/5may/tools/evaluation_feedback/en/
Ellingson K, Haas JP, Aiello AE,
et al. Strategies to Prevent Healthcare-Associated Infections through Hand
Hygiene. Infection Control and Hospital Epidemiology 2014; 35(8): 937-960
http://www.jstor.org/stable/10.1086/677145
SHEA (The Society for Healthcare Epidemiology of America). A
Compendium of Strategies to Prevent Healthcare-associated Infections in Acute
care Hospitals: 2014 Updates. Infection Control and Hospital Epidemiology 2014;
35(S2), September 2014
http://www.jstor.org/stable/10.1086/678317
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