Managing hand hygiene compliance

Hand hygiene compliance, with Ron Cagle of Sprixx, Jane Kirk of GOJO Industries, Jim Ingebrand of 3M Company and Cheryl Littau of Ecolab Healthcare.

“Many of the latest generations of products are formulated to help maintain skin integrity through inclusion of moisturizers and emollients”
-Cheryl Littau

In the last issue of EHM, we spoke to renowned infection control expert Elaine Larson about her ongoing research into the use of hand washing to prevent the spread of infectious disease. As well as undertaking a study into hand hygiene and H1N1, Larson, who is Professor of Epidemiology and Director at the Center for Interdisciplinary Research on Antimicrobial Resistance at the Mailman School of Public Health, Columbia University, has participated in the testing of the recently published WHO hand hygiene guidelines.

Part of Larson's research is aimed at discovering how viruses such as H1N1 spread, and what people can best do to protect themselves. "If we can determine whether the alcohol sanitizers or plain soap and water are better, then we'll know what to recommend for people to use," she told us. "And a better understanding of where the virus is spreading in the houses will help people know what they need to clean."

With the spotlight firmly on hand washing, and increasing pressure on healthcare institutions to comply with guidelines such as those released by the WHO, EHM gathered some of the industry's leading experts to examine the challenges, strategies and solutions surrounding hand hygiene compliance.

In your view, what are the current main challenges in hand hygiene compliance?
Cheryl Littau. One of the main challenges in hand hygiene compliance is ensuring that healthcare workers wash their hands at every hand hygiene opportunity. There are many factors that influence this, one of which is the interpretation of what constitutes a hand hygiene opportunity. Even though hand hygiene is considered a very basic requirement of a healthcare worker's job, interpretation of exactly when hand hygiene is needed can be an issue.

For example, contact with the patient environment is recognized by the World Health Organization (WHO) as an indication for hand hygiene, but healthcare workers may not be aware that they have touched a contaminated surface in the patient environment. Second, given the current environment of complex care, decreased staff and heavy work loads, hand hygiene is not always top of mind. Third, hand hygiene products are not readily available. Finally, skin health plays a vital role in hand hygiene compliance: dry, damaged skin can make hand hygiene a painful process. This can lead to a conscious or unconscious reduction in hand hygiene compliance.

Jim Ingebrand. Hand hygiene compliance is a critical component of addressing broader issues of healthcare-associated infections (HAIs), yet it is easily forgotten. Eighteen months ago when CMS announced it was discontinuing reimbursement for what it called 'never events', healthcare facilities increased their vigilance in the areas specifically outlined by the agency. However, some neglected to look at hand hygiene as a core component of all of those improvements.

The reasons range from systemic, including staff shortages and increased pressure to see more patients in less time, to environmental, such as inconveniently located sinks, a lack of supplies or education, and a lack of involvement among healthcare professionals in product evaluation and selection. The good news is that there is a renewed commitment to hand hygiene as an important HAI prevention measure, and hospitals across the country are taking action by increasing education and compliance.

Jane Kirk. The biggest challenge that I see with hand hygiene compliance is changing adult behavior so that hand hygiene becomes a habit for healthcare personnel. From my years of clinical experience and as a Director of an infection control program, I believe that healthcare personnel do not intentionally skip hand hygiene when they should be doing it, but rather they just don't think about hand hygiene, as they are thinking about their next task, the next patient they need to see, etc.

There are some healthcare personnel who are not aware of the guidelines for when hand hygiene is warranted, and the challenge to get the education presented to them in a way that they can make those opportunities part of their routine. Finding ways to break through the old habits and instil a culture of hand hygiene awareness and compliance is how we meet the challenge.

Ron Cagle. Change initiatives lack the comprehensive, multi-modal, multidiscipline approach required to be effective with such a tenacious long-standing problem. There is an overwhelming tendency to tinker - trying single or weak interventions, seeing how they work, then trying another. This problem requires a full complement of behavior and system change mechanisms that work in concert to drive change. The finger-wagging approach to compliance is as ineffective now as it was for Semmelweis when he stood over the sink admonishing and lecturing colleagues. Compliance measures that focus on policing providers while limiting system changes pit providers and their leaders against each other in a dysfunctional system. Group measures fail to make any one person accountable; therefore no one is. 

Which specific tools and techniques can healthcare organizations use to ensure they are able to meet these challenges?
JK. A healthcare personnel hand hygiene education program, a hand hygiene compliance monitoring process, and sharing of compliance rates with staff and resulting performance improvement programs are the key elements of a hand hygiene program. Having administrative support and the resources (both staff and financial) to implement an effective hand hygiene campaign are key elements for a successful hand hygiene program. Monitoring hand hygiene compliance to identify opportunities is very labor-intensive and ensuring that the hand hygiene program owner has the staff to conduct the audits is imperative to improving outcomes.

Best practices from effective programs across the country suggest that monitoring of compliance using observation methods should be conducted with a team of 'secret shoppers' comprised of individuals who are usually rounding on the units, such as wound care team nurses, or medical students. The WHO, the Centers for Disease Control and Prevention and the Joint Commission Hand Hygiene Monograph all provide many educational tools and ideas to help the process, such as observational tools and education components including videos. Resources and support to implement the program are vital to the IP's success.

Once observations or audits are completed, that information needs to be shared with everyone involved in patient care, including the staff who care directly for patients. Accreditation bodies such as the Joint Commission expect staff to be able to speak to the process improvement projects their unit is undertaking to improve compliance rates. Making hand hygiene compliance improvement a competition between units or divisions is a means to get staff and management engaged. Announcing monthly compliance rates at the manager's meeting helps to create an environment where successes are celebrated. Certificates of achievement could be presented to unit directors who show the most improvement and sustain that improvement. It is possible to make hand hygiene compliance competitive and fun!

RC. Achieving infection rate reductions through hand hygiene requires a comprehensive, multi-modal, multidiscipline hand sanitizing systems with true point-of-care access to sanitizer. The system should include: personal ergonomic sanitizer dispensers, individual episode performance feedback, multifaceted education, indication training, and a high-degree of leadership involvement. The change initiative should support personal, social and structural motivation and ability to raise hand hygiene to a much higher level of performance and clinical respect.

The WHO's '5-Moments' indications for hand hygiene have been translated into coming and going from the patient room out of practical necessity given current system limitations. Intra-operative hand hygiene is the key to lowering infection rates. The over-reliance on gloves is a major contributing factor to missed opportunities within the patient environment.

CL. First and foremost, healthcare organizations must have multidisciplinary, multi-faceted hand hygiene programs that are championed by strong administrative support. Clear, consistent communication that proper hand hygiene is important and valued by the organization is essential. Second, in order to make performing hand hygiene as time efficient as possible, it is important to provide product as close to the actual point of care as practically possible. If the alcohol-based hand rub is immediately at hand, the barrier to use is dramatically reduced.

Third, hand hygiene opportunities should be clearly defined. The WHO's 'My 5 Moments for Hand Hygiene' is an excellent tool to help reduce confusion about when hand hygiene is needed. Finally, assessment of worker satisfaction with the available soap and sanitizer products is key. Many of the latest generation of products are formulated to help maintain skin integrity through inclusion of moisturizers and emollients.

JI. Ideally healthcare facilities will institute compliance programs that fully address the intellectual (knowing the right thing to do), emotional (wanting to do the right thing) and behavioral (making it easy to do the right thing) aspects of the problem. Education is perhaps the single most important tool to increase hand hygiene compliance. From the top-down, it is essential to create a culture of compliance and develop the tools that fit within the culture. Many facilities provide updates on new products and directly involve healthcare professionals at every level in the trial and evaluation of these products, helping to increase adoption and acceptance. Others are conducting annual, validated competencies on application and purpose of hand hygiene for all staff to ensure ongoing compliance. 

3M has worked with facilities across the country using industry-leading Six Sigma methodology to improve hand hygiene compliance.  One project, initiated in 2006 - and still ongoing - with HealthEast Care System of Minneapolis and St. Paul saw an increase in hand hygiene compliance from 36 percent to 70 percent. Continuous compliance monitoring and the identification of physician role models further increased physician compliance to 90 percent or greater.

What role does good hand hygiene play in the prevention of MRSA?
RC. The fact that MRSA is being singled out is testament to how the current working interpretation of the CDC guidelines is failing to control emerging antibiotic resistant threats. When the guidelines came out, US hospitals responded by hanging wall-mounted sanitizer dispensers at patient room entrances, displaying educational hygiene posters and tracking soap/sanitizer inventory records. Wall-mounted dispensers are not true point-of-care access to hand sanitizer but a budget and operational-friendly approach that fits current attitudes. The 2008 Rupp et al. study demonstrated how the current working interpretation is failing to reduce infection rates.

The primary battleground for MRSA is within the patient environment. Ergonomic personal sanitizer dispensers give providers the ability to respond to every intra-operative hand hygiene opportunity, especially during peak workloads. With effective training, personal dispenser use becomes a second nature habit. Impeccable intra-operative hand hygiene is possible and the single most effective way to reduce MRSA rates.

JI. Hand hygiene helps remove soil, debris and micro-organisms from hands and forearms, keeping patients and other healthcare providers safe from bacteria that could lead to infection. More than any other intervention to prevent and control HAIs, including MRSA, hand hygiene remains the most effective and least costly intervention.

JK. Good hand hygiene plays a key role in the prevention of the spread of MRSA in healthcare facilities. The number one way germs are spread from one patient to another is on the hands of healthcare personnel. In the CDC hand hygiene guidelines, many studies are discussed that demonstrate that hand hygiene, using either soap and water, or an alcohol-based hand sanitizer (ABHS) will kill MRSA on hands. Studies have shown that when hand hygiene compliance increases, healthcare-acquired infections decrease and MRSA transmission rates decrease.

In an abstract to be presented at the 2010 Fifth Decennial International Conference on Healthcare Associated Infections, scientists will present a study that demonstrated that ABHS and 0.3 percent Triclosan, an antibacterial hand wash, were effective against MRSA, reducing levels on human hands by approximately 99 percent. The study also showed that four percent Chlorhexidine Gluconate (CHG) was less effective against MRSA, suggesting that CHG may not be appropriate hand hygiene for MRSA, particularly after a single use.

CL. Hand hygiene is critical to prevent transmission of MRSA. Colonization with MRSA is frequently undetected. There is clear evidence to suggest that MRSA is carried from one person to another via the hands of the healthcare worker. Hands are easily contaminated during caregiving or from contact with environmental surfaces in close proximity to the patient. Hand hygiene after such events has a very important role in preventing the transmission of MRSA. In situations where hands are not visibly soiled, alcohol-based hand rubs are very effective at killing MRSA, as well as many other organisms, providing both a rapid and high level of kill.

What recommendations would you make to healthcare organizations looking to introduce or improve their hand hygiene strategies?
JI. Considering that hand hygiene compliance is everyone's responsibility, a culture of compliance must begin with top management and extend to everyone who comes into contact with patients. Understanding what drives compliance within your institution is pivotal. Talk to your healthcare professionals and understand their challenges and needs. Consider Six Sigma projects to drive sustainability by improving processes, reducing variation and establishing changes that become permanent practice.

In addition, partnering with industry leaders with proven expertise in hand hygiene technology - who understand the critical factors when developing and executing a hand hygiene compliance program - will improve hand hygiene strategies dramatically. Researching emerging technologies to help improve compliance will also play a significant part. 3M, for example, is collaborating with Patient Care Technology Systems on technology that uses real-time locating systems to automatically and continuously evaluate staff members' hand hygiene activities throughout a patient encounter. Reports can be generated from the information captured during the hand wash and used for performance improvement projects and for training purposes. 

CL. Studies have shown that taking a multimodal approach to improving hand hygiene is superior to any particular single intervention for achieving and maintaining improvement in hand hygiene compliance rates. For example, Ecolab's multimodal Hand Hygiene Compliance Monitoring program helps hospitals to address the Joint Commission's National Patient Safety Goal 7A (that is, to comply with the CDC or WHO hand hygiene guidelines). The patient empowerment aspect of Ecolab's multi-modal Hand Hygiene Compliance Monitoring program ('It's OK to Ask') also helps hospitals to specifically address the Joint Commission's National Patient Safety Goal 13; that is, to actively encourage patients' involvement in their own care. Identifying and recruiting physicians and hospital administration as hand hygiene 'champions' can also be very beneficial in sending the message that proper hand hygiene is the responsibility of everyone within an organization. 

RC. Start by putting clinical hand hygiene into perspective. Hand hygiene is the flagship of patient safety. The overwhelming cost of hand-transmitted infections warrants serious reflection on our practices, budgets and attitudes. Significant improvements require new thinking, systems and commitment that reflects the cultural values to which healthcare aspires.

System change combined with new tools and approaches make it possible to significantly improve upon current hand hygiene standards. System change combined with effective hand sanitizing tools can transform hand sanitization from a friction-inducing tension between providers and their leaders into shared solutions that support intrinsic values. Everyone at every level - from the board to the housekeeping staff - needs to embrace significant change and personal responsibility for clinical hand hygiene evolution.

JK. I would recommend that the administration get involved and support the hand hygiene improvement projects and set an expectation of all staff to become engaged in the improvement of hand hygiene compliance and patient outcomes. Encouraging creativity and providing resources to implement the program has also been key in facilities that have seen improvement in hand hygiene compliance. Empowering the IPs to utilize the full resources of the facility, such as the media department for creating hand hygiene program initiatives, provides the support and encouragement an IP needs.

The organization needs to ensure that hand hygiene products are easily accessible and readily available so that staff can perform hand hygiene as recommended by the CDC. Safety issues such as hand sanitizer dispensers in the psych ward can be addressed by ensuring that the staff have personal carriage hand hygiene products. The cost of healthcare-acquired infections far exceeds the cost to provide staff with adequate hand hygiene products.

Dr. Cheryl Littau is a senior program leader for Ecolab Healthcare. She holds a PhD in surfactant chemistry from Emory University. Littau is directly involved in the formulation, testing and development of new products for use by healthcare workers. She can be reached at cheryl.littau@ecolab.com.

Jane Kirk, MSN, RN, CIC, is the Clinical Specialist for GOJO Industries, Healthcare Division, providing the infection control perspective to the Healthcare Marketing team. Kirk graduated from University of Detroit-Mercy with a Bachelor of Science in Nursing. She received her Master of Science in Nursing from Walden University.

As Marketing Director for 3M's Infection Prevention Division, Jim Ingebrand covers a range of markets from medical diagnostics to disposable medical supplies. This diverse set of businesses has the common mission to help 3M customers detect, prevent and control the risk of infectious disease and healthcare associated infections.

Ron Cagle, VP of Research  and Development, is the project leader for Sprixx, overseeing product development, marketing and business development. A 26-year product development veteran, Cagle holds multiple hand hygiene device patents. His 15-year computer industry career included nine years as a software engineer developing new entertainment, fitness and business software products. Email rcagle@sprixx.com.