Hand hygiene 2.0: Wash like no one’s watching
Observed compliance is great, but what happens behind closed doors?
Results from the first half of Asante’s hand-hygiene effort are in, and the numbers are impressive. Compliance at all Asante hospitals has soared to well over 90 percent month after month since the awareness campaign launched in November. In some months, adherence at Asante Three Rivers Medical Center and Asante Ashland Community Hospital reached 100 percent.
Figures at Asante Rogue Regional Medical Center, however, fell in February in March – the result of a change of observation protocol.
Asante infection prevention leaders are pleased with the results, but they’re also cautious. Compliance is measured by direct observation – how frequently staff members use hand sanitizer when entering and leaving a patient’s room.
Although this is a standard method of measurement across the country, it captures only behavior that can be seen by an auditor.
“Direct observation is vulnerable to the Hawthorne effect,” explains David Candelaria, MD, a hospitalist with Asante Ashland Community Hospital, who helped spearhead Asante’s hand-hygiene initiative. “That is, the observation itself changes behavior.”
A truer test of Asante’s dedication to hand hygiene happens when caregivers are not being watched. In particular, whether they follow proper hand hygiene for at least five critical points of care: Before patient contact, before an aseptic task, after risk of exposure to body fluids, after patient contact and after contact with the patient’s surroundings.
Fast fact: Good hand hygiene can cut hospital-acquired infections in half.
Infection preventionists are looking at ways to monitor hand-cleaning beyond entering and exiting patient rooms, but it still falls to every employee to be conscientious about hand hygiene at all times.
“Hand hygiene is essential to prevent hospital-acquired infections, including urinary, bloodstream and surgical-site infections as well as MRSA, C. diff and other potentially deadly microorganisms, ” says James Grebosky, MD, Asante’s chief quality and patient safety officer. “We owe it to our patients to maintain hand hygiene at all critical points of care — especially when no one’s watching.”
Who’s Responsible for Preventing Infection? Everyone
James Grebosky, MD
and patient safety officer Asante
Of all hospital-associated infections, Clostridium difficile has emerged as the 300-pound bug. The potentially deadly organism, which colonizes in the intestines after antibiotic therapy alters normal gut flora, has surpassed MRSA as the leading germ threat.
It can lead to pseudomembranous colitis, toxic megacolon, perforations of the colon, or sepsis. It infects nearly half a million Americans a year and kills more than 15,000.
Despite these statistics, one thing is encouraging: C. difficile infection is relatively easy to prevent. By following strict hygiene standards and practicing wise antibiotic stewardship, Asante hospitals want to reduce the number of hospital-acquired cases to zero.
Hospital staff and physicians must take several measures to prevent transmitting C. diff, including:
- Following contact enteric isolation practices. That is, wearing a gown and gloves whenever entering the room of a patient with C. diff, even when the patient is not present.
- Hand washing with soap and water. Alcohol-based hand rubs do not kill the organism (neither does soap, for that matter), but washing sloughs the spores off the skin and down the drain.
- Keeping equipment used to treat C. diff patients, such as stethoscopes, within the patient’s room to prevent cross-contamination.
- Cleaning with a sporicidal disinfectant, such as bleach or Peridox, instead of standard hospital disinfectants. C. diff spores can live a long time on surfaces such as bed rails and bathroom fixtures.
C. difficile should be suspected in patients with diarrhea who have taken antibiotics within the past two months or developed diarrhea while in the hospital. Patients with at least one episode of C. diff face a substantial risk of recurrence — and the need for even more antibiotics — so getting initial therapy right is essential.
Finally, help educate our patients and their visitors about infection risk. Patients with C. diff should not visit common areas, such as the cafeteria or gift shop. And their visitors should be instructed to wash their hands before and after entering the patient’s room, even if they wear gloves and gown.
With safe practices and vigilance, we can squash the C. diff bug before it spreads.
Fast fact: 80% of all infectious diseases are transmitted by touch.
Five moments for hand hygiene
A brief refresher on the when, where and why of proper hand cleaning
Asante employees have been great about using hand-rubs when entering and exiting patient rooms, but that qualifies as only two points of care. All employees who have contact with patients or their environments may need to clean their hands at least five times:
No. 1 Before patient contact
Examples: Shaking hands, clinical examination, helping a patient move, applying a mask
No. 2 Before an aseptic task
Examples: Oral or dental care, secretion aspiration, wound dressing, catheter insertion, food preparation, administering medications
No. 3 After body fluid exposure risk
Examples: Same as No. 2 as well as drawing or handling blood; cleaning up urine or feces; handling waste
No. 4 After patient contact
Examples: Shaking hands, clinical examination, after taking pulse or blood pressure
No. 5 After contact with patient surroundings
Examples: Changing bed linens, perfusion speed adjustment
Source: World Health Organization
Fast fact: Fingernails and nail beds harbor the most microorganisms.
Clean hospitals: It’s not just about the hands
Environmental cleanliness helps prevent the spread of infection, too
Imagine a pair of glasses that would allow us to view a hospital microscopically. Without proper cleaning, a patient room might have methicillin-resistant S. aureus on the bedrail, vancomycin-resistant Enterococcus on the doorknob, Klebsiella pneumonia on the light switch or C. difficile on the telephone.
When finished marveling at these teeming organisms we’d realize just what it takes to rid a room of these unwanted guests. Besides plenty of disinfectant, it takes attention to detail, vigilant monitoring, lots of staff training, encouragement, discipline and sometimes even a compelling patient story.
At each Asante hospital, cleaners from Environmental Services must disinfect up to 22 common touchpoints in every patient room, every time. These surfaces include everything from the bedrail to the IV pole to the light switch.
To ensure that these touchpoints are being routinely cleaned, auditors from Infection Prevention place a fluorescent dot on each of the targeted surfaces once the patient is discharged. After the room is cleaned, a blacklight will reveal any remaining dots, indicating that that particular touch point didn’t get wiped down.
If at least 80 percent of those surfaces are clean, the room earns a passing grade. If cleaning falls below that mark, staff members receive training or, in extreme cases, disciplinary action.
In January, Asante Rogue Regional Medical Center began trying to new approaches to ensure the 80 percent goal is reached every time.
“We’re putting a lot more emphasis on education,” says Barbara Curtis, director of Asante Performance Improvement. “Cleaning a hospital is very different from cleaning a home.”
Education may involve an observer watching while the housekeeper cleans and providing corrections in real time. Or it may mean explaining the devastating effect that a hospital-acquired infection can have on a patient.
Fast fact: 21% of health care workers in the ICU carry staph on their hands.
“That really touches them on a human level,” Curtis says. “It helps them understand how their work is critical to the patient’s wellbeing.”
Cleaners who receive perfect scores join the “100 Percent Club” and are rewarded with a special gift. Before the recent effort, only about half the rooms evaluated reached the 80 percent target. Since January, however, it’s common to see all the rooms reach the 80 percent target.
Drop (don’t toss) gloves in a proper receptacle. Wash your hands with soap and water or use alcohol-based rub. Gloves must be changed before and after each use with each patient (with hand cleaning before and after each use), and they should never be worn in common areas, such as elevators and hallways.
Five questions with James Grebosky, MD
Chief quality and patient safety officer, Asante
If doctors had brand slogans, Dr. Greboksy’s might be “Ever better.” Or, “Relentless.” Or, “Why isn’t that fixed yet!?” The drive to improve the quality of health care has vaulted the ARRMC medical affairs VP into the role of Asante’s first system-wide chief quality and patient safety officer.
Now Dr. Grebosky sets his sights on elevating clinical standards for all Asante hospitals.
1. What does your new role encompass?
I’ll be focusing on quality and patient safety in both inpatient and outpatient settings. Our aim is to ensure we provide excellent care 100 percent of the time.
2. What changes can people expect to see?
We do great work, which has made us a Truven 15 Top health system. So the goal is to continue that high level of quality. That said, we will pay close attention to hospital-acquired infections, medication safety and ambulatory quality.
3. What are the biggest obstacles to patient safety?
Compared to many health systems, we’re fortunate to have few major obstacles. We’ve got a great culture where people believe in and value patient safety.
4. You practiced family medicine before earning a master’s degree in health care management from Harvard. What drew you to the administrative side?
I haven’t practiced medicine where I haven’t been involved in quality. My wife, Becky, has a master’s degree in human factors and my mother-in-law holds a PhD in the subject. Both did in quality with Lovelace Health System in New Mexico, where I started, so they dragged me into quality projects early on in my career.
5. What are the hand-washing rules around your house?
Becky is tough about that. Our two boys are 14 and 16 and they’re not allowed to not wash their hands. The dogs have been harder to train.
Fast fact: 95% of people say they wash after using a public toilet -- 67% actually do.