Coming Clean on Hand Hygiene

Hand hygiene is the single most important procedure there is to fight hospital-acquired infections. That’s because the healthcare worker is the main carrier and transmitter of pathogens in hospitals. They pick up bacteria from patients and places, and pass then around: from hospital sink drains, on equipment passed from room-to-room, on door handles, on the hands of other clinicians and hospital workers, and in ventilators and tubes.

So how are we doing in our effort to keep our hands clean?

Most hospitals report compliance rates of about 50% for doctors and 65% for nurses. However, as low as those numbers are, they have been brought into question by a number of groups as being too optimistic.

For example, the Canadian health advocacy group healthydebate reports that most research has found hand washing to occur in about 40% of patient encounters. That the higher rates simply reflect how hand washing rates are measured; i.e. that  the audit of hand washing was announced to staff in advance, and the persons measuring hand washing announced their presence when they were on the unit. The director of infection control at the hospital suggested that “given a second chance, I’d do it another way.”

A study in the US at the well-regarded North Shore University Hospital in New York found rates to be even lower, at less than 10%. And this was in their intensive care unit. Moreover, US hospitals have built-in incentives to comply with hand washing because (1) they can lose Medicare money when patients get preventable infections, and (2) US hospitals are sued far more often than in Canada and hand-washing compliance rates often become part of the information used by plaintiff attorneys.

There is anecdotal evidence to suggest that the compliance rate can even be close to zero. I interviewed a senior who spent 6 weeks in one of Winnipeg’s larger hospitals this past spring. She reported that only on one occasion did hospital staff ever wash their hands – a nurse. What about the doctors I asked? No, never, she said. Would you ask them to? No, even though my daughter said I should. And why wouldn’t you ask them? Well because they come around so early in the morning. They wake me up. There’s always a bunch of them and no way am I going to tell them what to do – I need them.

Not only that, compliance numbers are collected on doctors and nurses only, yet we know hospital orderly’s have a lot of patient contact and that cleaning staff indirectly affect all patients.

And there is one more clue to suggest lower-than-reported numbers: evidence of the huge effort it takes to ensure compliance. At the North Shore Hospital mentioned above, they upped compliance rates to near 80% – by installing video monitors of the ICU and an LED board that gave a real-time running count of compliance rates.

But absent such an atypical intervention, how are we doing, honestly?

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