How Clinical Hand Hygiene Can Help Solve Healthcare’s Biggest Challenges

Challenges help create the condition for the dramatic evolution of business and clinical best practices. An advancing economic crisis, CMS phasing out payment for healthcare acquired infections, mandatory reporting, MRSA, and the nursing shortages are formidable challenges which together create conditions for the holy grail of patient safety to be found at last. The time has come for hand hygiene to evolve into an advanced clinical skill, emerge as the nucleus of a new patient safety culture, and provide fiscal relief in trying economic times.

No other single patient safety issue has more at stake for an institution in fiscal savings and improved patient outcomes than clinical hand hygiene yet improvements have been elusive.  Healthcare acquired infections (HAIs) can be cut in half given impeccable hand hygiene.  The release of the 2002 Centers for Disease Control and Prevention hand hygiene guidelines initiated introduction of wall mount alcohol gel dispensers and motivational posters in every hospital across the country.  Using observers and inventory records to measure, some hospitals boast compliance rates as high as over 90%.  However, infection rate improvements have not been realized as the stakes grow higher with emergence of MRSA and other antibiotic resistant organisms.

The fact is, until now, providers have not had true point-of-care access to alcohol sanitizers and therefore were not able to respond to hand hygiene indications which were logistically improbable. The CDC recommendation for point-of-care access to hand hygiene agents has been translated into wall mount dispensers situated near the patient room entrance. Infection preventionists and clinicians, by practical necessity, have translated the indications for hand hygiene recommended by the CDC guidelines into little more than coming and going from patient rooms. The act of coming or going from a patient room in itself is not a recommended indication for hand hygiene, as defined by the CDC guidelines. It is, however, an excellent practice, being well aligned with actual indications and serving as a prompt for hand sanitation which is a good start.  Conversely, the immediate patient environment; touching an IV pole, monitor, bedrail, chair, privacy curtain, etc... is a recommended hand hygiene indication yet is noticeably absent in both message and practice. The CDC guidelines point to studies showing hand-transmitted infection rates are highest during the busiest times.1 When patient-care duties are most demanding, how can a doctor or nurse respond as expected to every hand hygiene opportunity in the patient environment when the wall-mount dispenser or sink is many steps away? 

The solution to the persistent logistical barriers is at hand. A new system has been tested at Dartmouth-Hitchcock Medical Center which lights a path to a bright new future for hand hygiene and a powerful way for hospital leadership to meet the challenges offered by these remarkable times.  The Sprixx Hand Hygiene System (SHHS) is a new comprehensive system that provides the structure, process, and technologies needed to support sustained improvements including true point-of-care alcohol dispensing, training, performance feedback, fresh promotions, meaningful quarterly education, and multidiscipline organizational tools. The system is built and implemented using top business methods of our day: IHI Improvement Process, and Six Sigma Principles. SHHS includes:

• ultimate accessibility to alcohol hand rub using personal sanitizer dispensers at the point-of-care
• economical individual performance feedback using electronics in the personal dispensers
• a comprehensive multimodal program that includes training, education, tracking feedback, promotion and program management software all put in place to support the frontline providers

The new study abstract by Dartmouth-Hitchcock Medical Center (DHMC) of Lebanon, NH presented at the Society of Critical Care Medicine's annual Critical Care Congress in Nashville, TN reveals the promise of this new approach to healthcare hand hygiene and hospital infection rate reductions.  Tracking before-and-after infection rates in a 26-bed intensive care unit (ICU), researchers found introducing the use of Sprixx personal sanitizer dispensers with tracking electronics by the nursing staff, significant improvements in hand hygiene adherence corresponded to reductions in healthcare acquired infections (HAIs). The study documented improvements in both ventilator-associated pneumonia (VAP) and catheter related blood stream infections (CRBSI).  "Ventilator pneumonias were significantly reduced after introduction of the novel device [61% reduction, p=0.001, 95% CI (1.91-9.01)]."  The Sprixx body-worn hand sanitizer devices resulted in a, "trend towards reduction in catheter-related bloodstream infections by 50%."2

The Sprixx system uses Hand Hygiene Episode Measurement which is based on electronic usage data from the personal hand hygiene dispensers.  Every time the personal dispenser is used, a time and date stamp is recorded as a hand hygiene episode in a computer chip aboard the dispenser.  That data is downloaded into a computer.  Provider performance feedback and administrative reports are generated based on that data. 

The feedback from the time/date stamp data is in two basic forms:  episode counts for each working hour and the Average Hourly Episodes (AHE) for a shift or other time period.  The performance goal is to maintain consistent-use throughout a shift.  Multiple pumps of the dispenser are counted but summarized into discrete episodes.  The time stamp data makes attempts at gaming or fooling the system obvious.

Individual performance feedback is presented within the context of an individual performance Average Hourly Episode goal for each provider shift.  A goal is unique to the position and setting of each provider and is based on a collective national database.  It is the role of the collective national database and clinical studies to establish position and setting performance thresholds.  The objective of the system is to clinically tie thresholds to infection rate improvements.

SHHS uses episode measures to bring to clinical hand hygiene the central ingredient that is required to achieve and sustain significant compliance improvements - individual performance feedback.  In healthcare, improvements come from individual clinicians at the point of care and work their way up through study and systems development to become the standard of care.  It all starts at the individual provider level.  Without individual performance feedback, the fundamental ingredient of change is missing.

The Hawthorne Effect has been biting the hand of medical hand hygiene long enough.  When an Infection Preventionist steps onto a unit with a clipboard to record observations, it is funny how hand hygiene compliance suddenly sky rockets.  This may offer a slanted view of the measures, but it also gets providers to sanitize more often.  Electronic episode measures are like sending that Preventionist onto the unit 24/7. 

For substantial hand hygiene improvements to be achieved and sustained, providers must know that someone is monitoring performance and cares.  At some level they need to know consistent performance indicators below acceptable levels will result in some sort of tangible response as will performance at or above normal established goals will be recognized.  Without a sure response, the message is clear that hand hygiene simply isn't a priority, and therefore, doesn't matter. 

Providers need regular individual performance feedback to manage their own change and skill development.  We're not talking about a trivial change for clinicians.  First, we are asking clinicians to go from the national average of below 50% compliance to near-perfect.  We're not just saying it this time; we're going to measure it and follow everyone through the process of change and sustaining the improvements.  Opportunities within the patient environment can be responded to given a new second-nature sanitizer tool.  Developing the second-nature response to every indication for hand hygiene requires a professional commitment.  It is an advanced clinical skill that requires regular performance feedback. 

Transforming attitudes about hand hygiene from an afterthought into a highly regarded advanced clinical skill requires a new language for performance feedback.  Episode measures offer clinicians the language of individual feedback.  Given the individual measures, group measures too become more meaningful.  Individuals have the opportunity to see their performance within the context of the group paving the way for individual and group goals.

Electronic episode measures provide the backbone of an integrated multimodal and multidiscipline hand hygiene program.  A critical aspect of the system change introduced in the 2002 CDC guidelines was the requirement of introducing multimodal and multi-discipline dimension to hand hygiene programs.   Getting everyone involved at every level with many supporting components to the program offers the support required to drive change and sustain improvements.

The use of an online remedial education system is a perfect example of how electronic episode measures can provide the glue to an effective multimodal program.  Electronic episode measures make it easy to employ the Six Sigma mechanism of responding to a dip in performance with remedial education.   Education should be a component of the multimodal program per the recommendations of the CDC, WHO, and IHI.  An electronic episode system can generate a list of low performers and send out emails asking them to enter online remedial education for a quick refresher for continuing education credits.  It can then interface with the online education system to track successful completion of the course.

Episode measures provide the tangible framework to involve leadership at every level.  It provides a lexicon for performance giving leaders the ability to understand and participate in initiatives.

The characteristics of episodes measures are highly synergistic with the vision of a healthcare safety culture being painted by leading patient safety organizations.

Observation, wallmount counters, or inventory records measurement have tendencies harmful to the development of safety culture.  Hand hygiene observation indicators do not offer the kind of comprehensive and continuous measurement made possible by electronics.  The shortcomings of these measures include:

• Observation can be seen as acquired by "spies."
• Observation "spies" can be perceived as subjective and prone to perceptual gaps and personal bias.
• Having "spies" watching for missed opportunities has a connotation of blame; "Blaming is always counterproductive" to safety culture."³
• It is very difficult to measure every provider on a unit using observation. Someone always falls through the cracks limiting the true picture of overall adherence and leaving large gaps where under performers are left.
• Group measures lack individual meaning ultimately undermining the measures and the culture. Culture will not change unless the individual motivation to do so is made possible by individual performance feedback.

For feedback to most effectively support safety culture it must be a measure of everyone and be shared by everyone.   "High performing organizations are feedback-rich environments...This supports the value of safety in the organizational culture."   It is "important for workers and leaders to see it, as a measure of progress and a call to action...Seeing progress in this area is highly reinforcing to employees at all levels."³

Transparency has been proving itself in many industries to be a powerful attribute of safety culture.  Creating a climate of transparency starts with a systems approach to improvements, no-blame climate, goal orientation, and a sense of positive, shared purpose.  Episode measures are highly synergistic with these conditions.  Episode measures focus on driving up performance i.e. increasing continuous frequency of hand hygiene events.  It does not focus on nitpicking missed hand hygiene opportunities.  Everyone on a unit can see everyone else's performance yet everyone has unanimity within the team (see Figure 2 for the group performance poster).  Goals are promoted on both the group and individual levels.  This allows a natural sense of shared-purpose to arise without blame or embarrassment. 

With the average cost of a VAP at $40,000 and a CRBSI at $45,000, and CMS phasing out payments for infections, hospitals must embrace new technologies, systems, and safety culture.  To learn more about the Sprixx Hand Hygiene System and how your hospital can capitalize on the opportunity of today's biggest healthcare's challenges, call 866-477-7499 or visit www.sprixx.com. 

References:
1. Boyce JM and Pittet D. Guideline for hand hygiene in health-care settings. Morbidity and Mortality Weekly Report, Oct. 25 2002, Vol. 51, No. RR-16. Page 6.
2. Randy W. Loftus, Stephen D. Surgenor, Andreas Taenzer, Donna Houston, Cindy Robinson, Matthew Koff, Reduced Nosocomial Infections Associated with a Novel Point- Of-Care hand Hygiene Device, SCCM CCC 2009 Abstract, Feb.2009

3.  Krause TR, "Leading Through Safety"  Wiley Interscience, pg 143