Hand washing soars after IC posse hits the wards

Hand washing rate hits 94% with nurse observers

"Deputizing" nursing staff to monitor hand washing and other infection control measures by health care workers can sharply improve compliance and may even have a residual effect, an infection control professional (ICP) reports.

Staff compliance with hand washing has been shown to be notoriously low (in the 40% range) unless workers are aware of being formally observed, notes Janet Eagan, RN, CIC, MPH, ICP at Sloan-Kettering Cancer Center in New York City. It can be impractical, however, for infection control staff to monitor an entire hospital continuously, she notes, and thus she sought to increase surveillance for compliance throughout the hospital without increasing infection control staff.

Eight registered nurses — either clinical instructors or nursing supervisors — were "deputized" as ICPs after they were trained to observe and verbally correct staff during patient care activities using a standard monitoring sheet. (See monitoring sheet, p. 114.) On the sheet, each patient is assigned two lines and identified only by medical record number. The nurse observer checks off whether the health care worker is a nurse or physician and whether the patient is on precautions, circling "yes" or "no" for compliance with infection control precautions.

"The main [question] was, if they touched the patient, did they wash their hands?" Eagan says.

The sheet also was used to indicate which type of isolation precautions the patient was under, and if gowns, gloves, or masks were worn appropriately, she says. Eagan collected the sheets weekly and did a monthly compliance report based on the number of observations and incidences of noncompliance. The project lasted three months, and 1,200 observations were made on all shifts. The infection control compliance rate for each month was stable at 94% — partly because the health care workers quickly became aware of the deputies.

"In fact, it got to be a joke," Eagan says. "When they saw them walking around they turned on the water. But people got the hint, and they knew what they had to do. I felt that 94% compliance with hand washing was pretty good."

Perhaps the most difficult aspect of the project was reminding health care workers to wash their hands or correctly comply with some other infection control measure when they were observed out of compliance. Though the nurse deputies quickly became comfortable in doing so with their peers, some had trouble correcting physicians, Eagan notes.

"They were uncomfortable with it in the beginning, and so we did some role-playing," she says. "I told them if they had a lot of problems with it and didn’t feel comfortable that they should come to me and that I would make the correction or go on rounds with them. But within a week, everyone was fine. I think they just needed to see what the response was. In the end, after a very short time, they were able to correct physicians, nurses, whomever they had to."

The response was favorable, partly because the health care workers at the cancer center are well aware they are treating an immune-suppressed patient population that is clearly vulnerable to nosocomial infections, she notes.

"People just want to do the right thing, which is very impressive to me," she says.

"We had a Joint Commission [accreditation survey] a month after this finished, and they actually commented that they didn’t see one infraction of infection control. So we started with good compliance and I think we wound up even better."

The project was funded in a novel way, as Eagan convinced administration to let her use some of the funding from one unfilled full-time nursing slot and divide it among the nurse observers on an hourly wage basis.

"We used the funding from that position to pay per diem rate salaries to the clinical instructors and supervisors, so in other words we used eight people for one FTE," Eagan says.

"They each got a little bit of extra money on a per diem rate, and we got the end results. We had people out there all the time. We had 24-hour-a-day coverage on different units at different times, and we also taught them something that I had hoped subliminally they would continue to do — which they are doing."

Indeed, though the funding is no longer available to formally continue the program, the project seems to have yielded a residual effect because the nurses went through the process and now emphasize infection control in their daily rounds and activities.

"We would like to continue it, but I need to figure out a way to do it for nothing, because now we filled the position so we don’t have monetary reward for it," Eagan says. "I think it is a unique way of using everybody to do infection control, and I certainly think if other people can do it, it’s well worth it."

Such approaches may be one solution to maintaining infection control effectiveness in the face of staffing cutbacks, and Eagan is considering eventually expanding the model to include infection surveillance by nurses on individual units.

"We’re all experiencing the same things. Everybody is getting a little more work to do," she says. "So you don’t want to push this on them, but this sort of very subtly teaches them infection control. And that was always my goal. It’s not just the ICPs; it’s got to be everybody having the same knowledge and knowing the right way to do things. As facilities get downsized, you have to work more with who is out there."

Eagan presented her findings recently in New Orleans in a poster session at the 24th annual conference of the Association for Professionals in Infection Control and Epidemiology.