Don't get complacent with hand hygiene

(Editor's note: This is the second of a two-part series on prevention of hospital-acquired infections in the ED. This month, we give strategies to improve compliance with hand hygiene, tips for cleaning the equipment you use and tell you how to determine if your patient has arrived at the ED with an infection. Last month, we covered avoiding infections when invasive procedures are performed, reducing the risk of infection with peripheral IV insertion, using alternatives to invasive procedures, giving central-line education to ED nurses, and decreasing the use of central lines and urinary catheters.)

No matter how many hand hygiene signs you have posted in your ED, it might not be enough to ensure ED nurses wash their hands before and after every patient and use personal protective equipment (PPE) appropriately.

"ED nurses in particular can become complacent in this very important practice," warns Erin Aston, RN, BSN, an emergency nurse in the children's ED at WakeMed in Raleigh, NC. "The emergency nurse is pulled from one room to the next due to the urgent problems of their patients. Turnover is continuous."

This practice is particularly dangerous for some ED patients. "Immunocompromised patients are not uncommon. Care of these patients requires extra hand washing and PPE technique," she says.

Alexandra Penzias, RN, MEd, MSN, CEN, clinical nurse educator for the Department of Emergency Medicine at Tufts Medical Center in Boston, says ED nurses are at high risk for taking shortcuts with hand hygiene due to "the unpredictability of the environment, competing demands, and the increased acuity of the patient populations that we see." Here are three ways to reduce hand washing failures:

1. Place dispensers in strategic locations.

At Tufts Medical Center's ED, these were placed in hallways, waiting areas, by doors leading into and out of the ED, and inside and outside of each patient room.

"Patients find it reassuring to see staff practicing good hand hygiene," says Penzias. "We also have them by each of our desktops. Many practitioners pass through the ED and use the computers, so it is important to cleanse hands before and after documenting."

2. Prohibit artificial nails.

Penzias informed her ED nurses at staff meetings and by e-mail that artificial nails could harbor Candida, Pseudomonas, and methicillin-resistant Staphylococcus aureus, which then could be passed from patient to patient, or to their own families. "We encountered little resistance once the rationale was shared with staff," she says.

3. Perform audits.

At AtlantiCare Regional Medical Center City Campus in Atlantic City, NJ, "safety champions" in the ED work with the infection control department to conduct routine hand hygiene audits of hand washing practices. "Data from the audits is tracked and trended," reports Stephen R. Francz, RN, BSN, clinical manager of the ED.

At Signature Healthcare Brockton (MA) Hospital, hand washing audits compared compliance for physicians, nurses, and ED technicians. "It is important to involve staff in these audits, because often seeing is believing. Staff were more likely to evaluate their own practice if they thought they might be audited," says Kate MacKinnon, RN, CEN, nurse manager for emergency services. "Outliers to the process are provided with a percentage number that shows how many times they were observed washing their hands."


For more information on improving hand hygiene compliance, contact:

  • Erin Aston, RN, BSN, Children's Emergency Department, WakeMed, Raleigh, NC. E-mail:
  • Elizabeth Henderson, RN, BSN, MS, Emergency Department, Massachusetts General Hospital, Boston. Phone: (781) 706-7517. E-mail:
  • Kate MacKinnon, RN, CEN, Nurse Manager, Emergency Services, Signature Healthcare Brockton (MA) Hospital. Phone: (508) 941-7405. Fax: (508) 941-7475. E-mail:
  • Linda E. Reetz, RN, BSN, Director of Emergency Services, Beaumont Hospital, Royal Oak, MI. Phone: (248) 898-6260. E-mail:

ED makes changes to achieve compliance

Some strategies worked better than others

No ED nurse would argue that hand hygiene isn't important. It also might seem like an easy thing to accomplish.

"But, most of us can't boast favorable compliance rates," says Linda Reetz, RN, BSN, director of the Emergency Center at Beaumont Hospital in Royal Oak, MI. "Due to the nature of the service provided and the urgency of the care, the Emergency Center poses even more challenges in compliance than some other units." Here are changes that were made by Beaumont's ED nurses:

Education was provided, and signs were posted, to remind staff to practice hand hygiene.

These efforts were only "marginally successful," says Reetz. "And with the public becoming more aware of the need for meticulous hand hygiene, we really needed to step up our efforts."

Signs were posted stating, "It's OK to ask me if I washed my hands."

Although only a few ED patients have asked this question, nurses were armed with these possible responses: "Thank you for asking. I did wash my hands prior to entering your treatment bay," or "Thank you for taking an active role in your care. I plan to wash my hands right now."

"We stress that we are the ones inviting our patients to ask about our hand hygiene. Thus, we cannot get angry when they take us up on this offer," says Reetz.

Covert observations are done to identify compliance rates, which are posted monthly.

"We chose two staff members whose identity was kept from the staff," says Reetz. ED nurses are observed not only for hand hygiene before and after patient contact, but also whether it was done in compliance with established standards and whether gloves were used when indicated.

The number of hand hygiene stations was increased, with units placed inside and outside patient rooms.

"This has served to double our compliance rates. We took this one step further, by placing hand hygiene stations in our public waiting areas for visitors to use," says Reetz.

The covert observations had revealed that the ED nurses were most noncompliant next to higher-acuity beds and in the trauma room. "We decided that making hand hygiene stations or supplies more accessible in these areas would really make an impact in our compliance," says Reetz. "Thus, we placed dispensers on the walls in these areas when possible. We provided bottles of hand sanitizer in the room when the physical environment wouldn't house a wall dispenser."

See unwashed hands? You should speak up

What is the single best way to create a "zero-tolerance" culture for hospital-acquired infections in your ED? Peer accountability, according to Elizabeth Henderson, RN, BSN, MS, an ED nurse at Massachusetts General Hospital in Boston.

It's not enough to be vigilant in adhering to proper hand hygiene, making sure to disinfect before and after every patient contact, says Henderson. You must be sure your peers also do so.

"Don't remain silent when you observe improper techniques," says Henderson. "Do not be afraid to confront other nurses and members of the health care team when such practices are not followed."

Erin Aston, RN, BSN, an emergency nurse in the children's ED at WakeMed in Raleigh, NC, says you must "hold co-workers accountable for their hand washing techniques, or lack thereof. Don't be afraid to speak up when protocols are not being followed."

At Beaumont Hospital in Royal Oak, MI, feedback between ED nurses was "much more effective" than education given at staff meetings, reports Linda Reetz, RN, BSN, director of the Emergency Center. "Through informal coaching, we introduced communication techniques and scripting that could be used to address colleagues who needed to be reminded about hand washing," she says.

Clinical Tip

Put clean gloves 'at arm's length'

Starting intravenous lines, drawing blood, processing of point-of-care tests, changing stretcher linens between patients, and wiping down equipment between patients are all procedures that might expose you to bodily fluids. Chances are, though, you don't wear clean gloves each and every time.

To address this, boxes of gloves in every size — small, medium, and large — conveniently are placed "at arm's length for use in patient care," says Alexandra Penzias, RN, MEd, MSN, CEN, clinical nurse educator for the Department of Emergency Medicine at Tufts Medical Center in Boston. "Clean gloves are available in each of the patient rooms, on the supply and procedure carts, in our point-of-care lab, and in our utility rooms."

ED technicians ensure that these are stocked in all sizes, and ED nurse managers perform ongoing surveillance "to ensure that staff are utilizing gloves as appropriate, to prevent hospital-acquired infections," says Penzias.

Your hands may be clean, but is equipment dirty?

It's ultimately your responsibility

You discharge a patient, sit down to document, then an emergent patient is placed in that same room. This begs the question, "Who cleaned this room and equipment?"

"The nurse still might be documenting on the patient that previously occupied the room. Sometimes, they have no control over an emergent patient being placed in that room where possibly the equipment was not disinfected," says Erin Aston, RN, BSN, an emergency nurse in the children's ED at WakeMed in Raleigh, NC.

Or a patient might be rushed back to the patient care area at a time when no beds are available. "In this type of situation, a patient needing minor care may be moved to a triage room or a hallway stretcher," says Aston. "Protocols for cleaning equipment need to be in place in order for staff to know what equipment is clean or dirty. We care for multiple patients, suffering from minor illnesses to acute traumas. Our responsibilities can range from cleaning the stretcher and IV pump to saving a patient's life."

You might clean your hands before and after each patient contact, but what about your equipment? Elizabeth Henderson, RN, BSN, MS, an ED nurse at Massachusetts General Hospital in Boston, says, "Unfortunately, this is not always the practice. EDs are stocked with a wide variety of equipment that unfortunately is not properly cleaned, or sometimes not even cleaned at all, in between uses."

There are often "territory wars" between clinicians and housekeeping staff over whose responsibility it is to clean equipment, adds Henderson. "Ultimately, it is the clinician's responsibility that is caring for the patient," she says. Henderson says to follow these steps:

  • Wipe counters with an antibacterial solution. "Cables and wires should be wiped off and free from blood or any surface contaminants," says Henderson.
  • Clean pieces of equipment used by all nurses, such as stethoscopes, otoscopes, and blood pressure cuffs, in between patient uses. "Studies have shown that micro-organisms such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci have been cultured from these devices," says Henderson.
  • Wipe computer keyboards and mice at least once per shift with the proper disinfectant.
  • Learn about the cleaning and disinfecting products used.

Henderson says you should read the manufacturer's instructions beforehand, to see what type of surfaces it is used on, such as porous vs. nonporous. Also, most commercial bleach wipes need to allowed to dry for at least one minute on the surface. "Knowledge of the proper type of product, as well as its proper usage, is the responsibility of every practitioner," says Henderson."