Hand Hygiene – Basic steps your facility can take to fight healthcare acquired infections

By Jane Kirk

In our world of uncertainty concerning healthcare and the economy, and when each year more than 1.7 million patients in the USA acquire infections while in healthcare facilities, going back to basic steps like hand hygiene are critical for the survival of the healthcare institution.¹ Healthcare associated infections can result in untoward outcomes such as escalating cost of care, increased morbidity and mortality, longer length of stay without reimbursement, as well as the pain, suffering and loss of livelihood a patient and family may experience.

The Centers for Disease Control and Prevention (CDC) states that hand hygiene is the number one way to prevent a patient from acquiring an infection while hospitalized.² The CDC Hand Hygiene Guideline was published in 2002, and yet the national average rate of hand hygiene adherence remains at 40% today.³ Most healthcare facilities have made some improvement in the last 8 years, but it is not enough. Would it be acceptable for drivers to stop at red lights 40% of the time? Going back to the basic steps like hand hygiene can be challenging to Infection Preventionists who usually implement the Hand Hygiene programs in the facility, but it can be done with administrative support. There are many reasons to invest in an Infection Control Hand Hygiene program, and some of the reasons include:

• Patient Safety
• Increased hand hygiene compliance leads to decreased healthcare acquired infections
• Cost savings - Good Infection Control programs can save a hospital millions of dollars
• Consumerism - Patients are more likely today to "shop" for their hospital and healthcare provider including looking at published infection rates reported by the hospital
• Employee Safety - hand hygiene compliance will decrease employee healthcare acquired infections and absenteeism
• What better public relations and risk reduction than for patients and families to see that staff at this hospital care enough to take a moment to clean their hands before initiating an interaction with the patient?

Patient Safety

There are many drivers of Patient Safety including The Joint Commission. National Patient Safety Goal 7.01.01  requires hospitals to have a Hand Hygiene program and comply with either the current CDC or World Health Organization (WHO) hand hygiene guideline⁴. In April 2009 the Joint Commission published the monograph Measuring Hand Hygiene Adherence; Overcoming the Challenges with a goal of providing practical solutions for strengthening measurement and improvement activities. In the monograph, it is stated that "administration determines resources to available for hand hygiene measurement and improvement, including adequate infection prevention and control staff, resources for education, and the like. In addition, administration leaders do the following": ⁵

• Set expectations for the staff and for the board by determining organizational priorities.
• Motivate staff through leading by example by performing hand hygiene and participating in performance improvement initiatives
• Remove structural barriers to eliminate problems associated with inconvenient access to products
• Establish accountability and consequences for hand hygiene non-compliance
• Celebrate successes throughout the organization and within departments

Joint Commission Leadership Standard 01.03.01 states that "the governing body is ultimately accountable for safety and quality of care."  This includes that the hospital leaders must provide direction and adequate resources to the Infection Control program. Adequate resources include adequate staffing of the Infection Control Department. In 2002, The Delphi study was done to determine adequate staffing requirements for Infection Control programs in U.S. Healthcare facilities. The study recommended a ratio of 0.8 to 1.0 Infection Control professional for every 100 beds in the facility.⁶ Very few facilities meet those staffing recommendations eight years after the study was published.

Joint Commission Leadership Standard 03.01.01 requires that "leaders create and maintain a culture of safety and quality throughout the hospital." A culture of safety is defined by the Institute for Healthcare Improvement IHI) as an atmosphere of mutual trust in which all staff members can talk freely about safety problems and how to solve them without fear of blame or punishment." The IHI cites examples of hospitals with a culture of safety including hand hygiene. Some of the features of these successful programs included⁷:

• Administrative support
• Recognizing hand hygiene champions including physicians
• Evidence based hand hygiene education programs
• Alcohol based hand rubs and gloves readily available at the Point of Care
• Competency and compliance routinely monitored
• Feedback provided so that all staff knows their unit's most recent compliance rates
• Posters and reminders involving all disciplines of staff

Cost Savings

According to the CDC, 1 of every 20 (5%) patients will acquire an infection during their hospitalization. This leads to $26-$33 billion in excess healthcare costs, but what do those numbers mean to a hospital?  A patient who acquires a central line related bloodstream infection has an estimated excess cost (the cost incurred as a result of the infection over and above usual costs) of $36,441.00⁸. As a result of the Deficit Reduction Act of 2005, Medicare will no longer pay for the increased cost of certain conditions if the condition was not present on admission, and central line related bloodstream infections are included on the list of Infections. The infection also increases the patient's length of stay by 28.4 days⁹. No price can be assigned to the pain, suffering or loss of a loved one due to a healthcare acquired infection (HAI).

Administrators might view the Infection Control program as a cost center. The costs cannot be passed onto anyone, and therefore the Infection Control Department is often viewed as having little value since it does not generate revenue. A better way to view the Infection Control Department is as one of prevention and cost savings. With adequate resources, an Infection Control Department can save a hospital hundreds of thousands of dollars.

Consumerism

A new generation of patients, baby boomers are accessing healthcare and populating hospital beds. They have become accustomed to researching any major purchase and that includes healthcare. They expect transparency. Consumer Union, publisher of Consumer Reports publication, has a website that allows the reader to find their hospital and view a hospital rating report card, based upon patient surveys and information on infection control. A recent article in Consumer Reports, "Many Hospitals Fail to Lower Infection Rates"¹⁰, has received much attention. The article describes a "culture of secrecy" where previously hospital infection rates have been kept from the public. Consumer Reports advises consumers of healthcare to be wary of hospitals that refuse to report their infection control and patient safety data. Consumer Reports has recently been generating more awareness around infection rates and the role hand hygiene plays in yet again another effort to educate consumers. . Go to http:/www.consumerreports.org/health/doctors-hospitals/hospital-ratings.htm to see their recent efforts. The publication also describes what patients can do to protect themselves when hospitalized. Consumers are advised to insist that caregivers clean their hands with soap and water or alcohol based hand sanitizer before touching a patient. Patients and their families should feel reassured that there will be no repercussions for asking the caregiver to clean their hands. Patients should also be given the products and assistance to clean their own hands while in the healthcare facility. Often hand hygiene products are not within the patient's reach. A patient could fall reaching for a distant wall with the hand sanitizer.

The Joint Commission together with the Center for Medicaid & Medicare Services (CMS) have a national campaign called "Speak Up'' to urge patients to take a role in preventing health care errors by becoming active, involved and informed participants on the healthcare team¹¹. The program features brochures, posters, and buttons on a variety of patient topics encouraging the patient to speak up. One of the most utilized pamphlets, "5 Things You Can Do to Prevent Infection" includes advising the patient to clean his hands and ensure that the Health Care provider cleans their hands.

In summary there are many reasons for hospital administrators to support a Hand Hygiene program. Taking the basic step of partnering with the Infection Control Department to ensure that they have adequate resources for a dynamic hand hygiene program can provide benefits that exceed expectations. Some of the benefits include decreased hospital acquired infection rates which increase cost savings by reducing length of stay and non reimbursable expenses; decreasing legal costs, and most importantly improved patient safety and satisfaction.

References:

^1,8 Parekh, A. (2008). HHS Efforts to Reduce Healthcare-Associated Infections. Retrieved February 5, 2010 from: www.cdc.gov/ncidod/dhqp/pdf/hicpac/HHSpresentationHICPAC_11_08

² Boyce, J. (2002). The Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings (51), RR-16

³ Center for Disease Control, Office of the Director (2009). Public Health Grand Rounds, Toward Elimination of Healthcare Associated Infections Retrieved February 5, 2010 from: www.cdc.gov/about/grand-rounds/archives/2009/downloads/GR-101509.pdf Slide 12 of 81

⁴ The Joint Commission. 2010 National Patient Safety Goals retrieved February 5, 2010 from: www.jointcommission.org/patientsafety/nationalpatientsafetygoals

⁵ The Joint Commission (2009).Measuring Hand Hygiene Adherence: Overcoming the Challenges. Oakbrook Terrace, Illinois, The Joint Commission

⁶ O'Boyle, C. & Jackson, M. (2002). Staffing requirements for Infection Control programs in US healthcare facilities: The Delphi Project. American Journal of Infection Control. 30(6) 321-334

⁷ Institute for Healthcare Improvement. How to Guide: Improving Hand Hygiene. Retrieved February 5, 2010 from: www.IHI.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/HowtoGuide/ImprovingHandHygiene.htm

⁹ Pennsylvania Health Care Cost Containment Council. PHC4 Research Brief, March 2006. Retrieved from www.phc4.org/reports/researchbriefs/032906/docs/researchbrief2006report_hospacqinfections.pdf

¹⁰ Consumer Reports (2010). Deadly infections: Hospitals can lower the risk, but many fail to act. Retrieved February 5, 2010 from: www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/overview/deadly-infections-hospitals-can-lower-the-danger.htm

¹¹ The Joint Commission. Speak Up Initiative. Retrieved February 5, 2010 from: www.jointcommission.org/patientsafety/speakup