It is been a dozen years since Rekha Murthy, MD, FRCP(C), FACP, FIDSA, FSHEA, medical director for the epidemiology department at Cedars-Sinai Hospital in Los Angeles, really started working hard to make good hand hygiene a habit for everyone at the hospital. In the intervening years, the hospital has gone from having hand-washing rates in the 70s to consistently over 95%.
At a 950-bed hospital, that is an accomplishment: It is akin to turning a large ship around. A ship with many captains, all of whom thought they had really clean hands.
The big breakthrough came when the Centers for Disease Control and Prevention endorsed the use of alcohol hand rubs in 2002. In Cedars-Sinai, all rooms are private, and using the bathroom sink was often inconvenient or seen as an intrusion, says Murthy. Unit sinks were down the hall, so between each patient visit, a provider or nurse would theoretically have to go back and forth to wash his or her hands. “It was cumbersome.”
The alcohol gel meant that they could — and did — install dispensers at every doorway. But convenience wasn’t enough. Murthy says they had to look at other barriers and how to help make it routine. “Think about seatbelts,” she says. Initially, they were in cars, but people didn’t use them very often. There were ad campaigns. But until car makers started adding alarms and making passive restraint systems such as automatic shoulder harnesses, there wasn’t a lot of uptake. With the changes, people had to work harder to not put them on. Now it is a habit for most people. She wanted to do the same thing with hand-washing. “What did we need to do to make it possible, probable that they would do what we wanted them to do.”
The alcohol was the catalyst. Next was getting people to use it. That meant creating a policy, educating people about it, monitoring it and measuring success, and providing feedback.
The policy was that everyone who entered a patient room, regardless of what they did in that room, was to use the gel when they entered and gel when they left. “Gel in, gel out,” she says. They told everyone they would audit performance on this policy and give unit-specific data out to everyone.
There quickly developed a sense of competition between physicians, nurses, and environmental services. The latter got better the fastest and stayed the best. The doctors? They were the worst.
The problem was they were only hitting about 80% overall. That wasn’t good enough, she says. They did a pilot program that involved coaching between the offending party and his or her supervisor. The first time someone was observed by the auditor, the noncompliant person’s name was given to his or her supervisor. They were told that it was an expectation the needed to be met, and that next time, there would be consequences, such as a class, and the consequences would be noted in the person’s evaluation if necessary.
Physicians had a similar experience. They were told if they were caught not doing what they should be doing, they would get a letter that outlined the policy and noted that they were being informed of it. If there was a second offense, the department chair would send them to a 45-minute class taught by one of Murthy’s nurses that included online elements, a test, and then post-test discussion. The data about which physicians are not compliant with the policy is sent on to the medical executive committee. “It provides a level of accountability,” she says.”
Some of the physicians became instant converts, Murthy says. Most left the classes with new knowledge. And while there have been a few repeat offenders, the fact that they have their names posted at committee meetings is embarrassing enough that the number of physicians who have had three offenses has been vanishingly small. For those, Murthy says they are asked why they can’t follow the policy. “We make it about how we can help them comply, about what the barrier is, not that they are a bad person.” It hasn’t happened in ages, though, she says.
She went further with the doctors, too, spending one meeting culturing the hands of every physician, letting the germs grow, and then posting pictures of what exactly they were carrying around with them when they weren’t freshly washed or gelled. “They were all horrified,” Murthy says.
It was interesting as she went through the process to hear the reasons why people said they didn’t wash their hands. Some reasons were system problems — such as supplies not being filled or dispensers being broken. But most were personal barriers. Murthy says if a person wasn’t sick, they figured it didn’t matter. “They might say, ‘Oh, my patients never get sick,’” she says, failing to note that they were in a hospital where everyone around them was sick.
A lot of people said that they had too much stuff in their hands to wash, so they put a table near the gel dispensers where anyone can put their things (often themselves very germy) down to gel in or out. Others complained of skin sensitivity or of dryness as a result of all the hand-washing. The hospital has lotion dispensers spread around the facility and also has staff available to help troubleshoot specific skin problems that gel users may have.
“You can see the difference just walking down the hall,” Murthy says. “Ten years ago, I would watch people go through their day and see the lapses. Now, I see people stop at the dispenser and pump as they go into the room and do the same as they leave. It is what we strive for. It has become our culture, and that’s the tipping point for sustainability. We got to the point where it has become as thought-free as seatbelts.”
She continues to push the issue. She shares data with everyone, and not just about compliance. Infection outcomes seem to be impacted by the improved efforts, so she shares those numbers, too. There are extremely low rates for hospital-acquired resistant bacteria in the facility, such as MRSA, for example.
New transplant program physician leaders have been pleasantly surprised at how well patients do at Cedars-Sinai, Murthy says, and how few infections they get. She thinks that’s related to the hand-washing, too. “It is hard to untangle from other efforts, but I think there is a link.”
And saying so to staff resonates as much as pictures of what is growing on the doctors’ hands, she says. “They didn’t used to think it mattered, but the power of the anecdote about the patient who got well faster means something.”
The marketing doesn’t stop, all these years on, says Murthy. There are screen savers and posters everywhere, including in every elevator. Their message? “Germs are like opinions. Everyone has them. So please clean your hands.”
For more information on this topic, contact Rekha Murthy, MD, FRCP(C), FACP, FIDSA, FSHEA, Medical Director, Hospital Epidemiology Department, Cedars-Sinai Hospital, Los Angeles, CA. Telephone: (310) 423-5574.