Program improves hand hygiene compliance

HAIs, mortality rates reduced in PICU

An infection prevention program in a large pediatric intensive care unit successfully reduced hospital-acquired infections and improved mortality rates among children admitted to the unit in 2007–09, according to a recent paper in Health Affairs1. The program, which involved improved practices in hand hygiene, oral care, and central-line catheter care, resulted in:

  • 2.3 fewer days in the hospital per patient;
  • a reduction in hospitalization costs per patient of $12,136;
  • mortality rates 2.3 percentage points lower, compared to patients admitted before the interventions.

"Selling a change in practice is not easy," says Bradford D. Harris, MD, who is currently a medical officer at the Food and Drug Administration in Silver Spring, MD, but at the time of the initiative was a practicing intensivist who spearheaded the program.

The initiative began, he recalls, by reviewing how many infections the unit had, and by reviewing existing literature. "Fortunately there's a good body of literature out there, so we looked at the evidence and saw what seemed to work consistently," says Harris. "We noticed, for example, that the IHI bundle did not include oral care, so we included that in our bundle."

Harris explains that oral care involves scrubbing the patients' teeth and tongues every four hours, and at least twice a day using antimicrobials. "This helps eliminate the colonization of hospital pathogens and keeps inflamed gums down — which makes a big difference," he says.

In terms of reviewing recent performance, Harris's team found that while there had been 32 infections in the prior year, only one was insertion-related. "Everything else had occurred a minimum of three to seven days out, so we were clearly not following the best practice in terms of how to care for line dressings and access lines, so they became the foci of how we changed practices," he says.

Observation is instructive

The next step, Harris says, was "to see what we were actually doing." Since his entire team worked in the unit, they all observed what was going on. "One thing that became very apparent quickly was that people were not washing their hands," he says. "So this became central to both projects [oral care and catheter care]."

An initial staff survey was conducted, asking staff members what they considered to be most important. "After getting our preliminary data, we set up focus groups and asked what they were thinking about, and showed them our hand hygiene compliance; the fact that only 30% of the staff were compliant with keeping the head of the bed elevated; and that oral care varied tremendously depending on the nurse, the day, and the shift," says Harris. "It really became clear to us what we had to target."

In addition to the variation that was found, Harris reports "some pretty shocking quotes" in the focus groups. For example, he notes, one individual said, "It's not my grossness — it's theirs."

This was an eye-opener for the team, he admits, and it "really got discussions going."

Reminding staff

The next step, says Harris, was to monitor whether staff members were washing their hands, and mentioning it when they weren't. "We'd say something like, 'I see you're not washing your hands; would you mind doing it?'" he says.

There was "a lot of resistance all the way around," says Harris, but by enlisting some managers to do observations of their own units, monitoring became educational. "They'd come back and say, 'Yeah, we're not doing so well,'" he says.

The process was also educational because sometimes failure to wash hands was just the result of staff members not knowing they were supposed to do so between certain processes. "This really helped," Harris says. "And when they saw me and other doctors back them when confronted by outside groups it sent the right message."

For the two projects, says Harris, a large educational fair was held, which involved information on oral care, what constitutes good hand hygiene, and how to access central lines. "We launched the fairs on all shifts and also followed up with daily and weekly audits," says Harris. Again, he notes, staff members were notified when they were not being compliant.

"It was clear they were getting a lot of pushback from people who were not based in the unit," Harris says. "I then got a lot of support from epidemiology, which would send the offending person an e-mail. If that did not work, a second e-mail went to them and their supervisor. The next step, if necessary, involved backup from the chief medical officer and the nursing officer, so clearly there were teeth behind it."

Additional aids provided

Harris says the team also provided the staff with pre-packaged oral cleaning kits that were hung on the walls of each room. "They were a visual reminder," he explains. "They facilitated change in the process and made it convenient, too."

When it came to hand hygiene, he continues, his team noted that while there were sinks in the room, the alcohol foam was located outside the room. "We put Purell gel containers right on the nurse's work station and on the ventilators," he says. "This was also convenient and a visual reminder." In addition, he says, the team has reinforced good behavior. "We say 'Thanks, I saw you wash your hands — that was great!'" he says. "It's really helpful for people who resist at the beginning to say 'Good job.'"

As for other keys to success, Harris says one was identifying champions on the unit that got on board from the beginning. "The other is that it's absolutely critical to have the nurse administrator backing it," he says. As an example of what a champion can mean, he notes that it took him six months to get the hospital to allow the purchase of the oral care kits. "I got the company to agree to supply us for two months for free, but then I told the chief medical officer I needed his help to get this through purchasing — and he did," Harris shares.

[For additional information contact Bradford D. Harris, MD, Food and Drug Administration, Silver Spring, MD at (919) 593-0755.]


  1. Harris BD, Hanson C, Christy C, Adams T, et al. Strict Hand Hygiene And Other Practices Shortened Stays And Cut Costs And Mortality In A Pediatric Intensive Care Unit. Health Aff September 2011 vol. 30 no. 9 1751-1761.