In the seemingly endless array of interventions to improve compliance with the cardinal principle of infection control — hand hygiene — we have seen both carrots and sticks, electronic monitoring and the spying of secret observers.

But if the highest calling in the profession is to protect patients, what if they are the ones asking the providers to wash their hands? It’s been tried before with mixed results, but researchers in an ongoing study are adding a new feature.

A physician involved in the study went through the following script when first meeting the patient, explaining that hand hygiene was part of the treatment plan.

Motivational Dialogue

“I as your doctor would like to remind you that our team is committed to your health. One of the ways is cleaning my hands. (Demonstrates use of hand sanitizer.) Hand cleaning is an essential part of your care and keeps you from getting an infection. All healthcare providers, including doctors and nurses, should clean their hands before touching you as a part of your treatment plan. When you do not see them clean their hands, I am asking you to remind them to clean their hands prior to touching you. Do you have any questions? Will you repeat what I just told you? Just remember: All you have to do is raise your hand and say, ‘Clean hands, please.’”

The number of patients asking providers to clean hands increased by 63% after the intervention, suggesting that the approach promoted self-advocacy for hand hygiene, said Patti Grota, PhD, CNS-M-S, CIC, FAPIC, assistant professor of nursing at UT Health of San Antonio.

“[The physician] actually demonstrates the process of hand hygiene while delivering the message. Telling them, ‘This is part of your care,’” she said. “The substance of this intervention is really based on empowering the patient. Handing off the power to them, and saying I am demonstrating that this is important.”

The study is ongoing, but Grota presented some preliminary data on oncology patients recently in Minneapolis at the annual conference of the Association for Professionals in Infection Control and Epidemiology.

“We chose this particular group because they are in treatment, they are followed at their clinics, and they are immune-compromised and at high risk of healthcare-associated infections,” she said.

Hand hygiene compliance has been a historical bane for IPs, with healthcare workers about as likely to comply as a flipped coin turning up heads. Of course, many facilities are well above this 50-50 rate, but IPs report that it is difficult to “sustain the gain” with any given intervention.

While recorded compliance rates from observations or other surveillance measures may look impressive on paper, The Joint Commission is looking less at documents and more at worker practices. As of the beginning of this year, surveyors observing someone failing to wash their hands may issue a citation to the facility.

“Now, our compliance rates [on paper] aren’t nearly as meaningful, because if they observe someone not using hand hygiene, you can be cited,” Grota said.

The primary intervention with the script takes less than 90 seconds, so the method would be feasible if the study supports its efficacy.

However, it is difficult to empower patients who may have personal, cultural, or other issues that make them reticent to address their healthcare provider this way.

“The context is very complex when you start talking about empowerment of patients,” she said.

For example, Grota told of a conversation with an epidemiologist who knows full well the cause and effect that can lead to a healthcare infection. The epidemiologist said she was lying on a surgical table, feeling acutely vulnerable before a procedure, and noticed that the surgeon had not washed his hands.

“She couldn’t ask him,” Grota said. “She was vulnerable because he was doing the surgery. We have to create a safe, secure environment for this so patients are willing to take a risk.”

‘Looked at Me Like I Was Crazy’

Patients may fear that the provider may take offense, potentially affecting their care. Some of the comments by study participants include:

• “I do not feel comfortable because I didn’t want to insult the healthcare provider.”
• “I felt much more comfortable asking healthcare providers to wash their hands after participating in the study. It is all about how you ask.”
• “It took me a few times before I didn’t feel intimidated to ask.”
• “I asked a doctor and he looked at me like I was crazy. I felt bad. I was scared to ask again later.”

Indeed, a lot seemed to depend on the reaction patients got the first time they asked the question, and some of those getting a negative reaction did not ask again.

“These are things that they told me in the interviews that they had experienced,” she said.

“Even though it is very qualitative data it begins to guide and direct us toward what we need to address when we talk about empowering the patient.”

The sample represents a vulnerable population of primarily Hispanic women who were not highly educated. Most had knowledge of hand hygiene differences, but mistakenly thought it was permissible for healthcare workers to walk into their room with gloves already on.

“There was the possibility the culture at the clinic was impacted, since patients toward the end of the study reported that hand hygiene of the healthcare providers improved,” she said.

“As we continued the study over several months, there was some cross-pollination in the clinic and more healthcare providers were washing their hands.”

The intervention has promise, in part because it hinges on establishing a relationship with a primary healthcare provider who emphasizes the importance of hand hygiene at the start of the treatment plan, she said.