Hand washing: Ease of access and patient pressure

Patients urged to ask caregivers to wash hands

Placing a waterless hand-washing agent at bedside was more effective in increasing compliance with hand-washing recommendations than a novel effort to enlist patients to apply "social pressure" by urging care-givers to wash their hands, researchers report.

The findings were based on a clinical study by Werner Bishoff, MD, and infection control colleagues at the Medical College of Virginia Campus of Virginia Commonwealth University in Richmond. Poor hand-washing compliance has been long reported by ICPs and hospital epidemiologists, but the issue has taken on a new urgency with the spread of antibiotic-resistant pathogens that can be communicated on the unwashed hands of health care workers. The researchers looked at hand-washing compliance without any interventions and then again after introduction of education/feedback to workers, social pressure approaches using patients, and engineering improvements to increase accessibility and ease of use of hand-washing products.

"To generate social pressure from patients, pamphlets describing the importance of hand washing were distributed initially to all patients on the general ward and then to every new admission," Bischoff tells HIC. "The idea was to use the close patient/health care worker relationship for the transfer of information regarding hand washing. Generating [such] an atmosphere — where patients routinely remind the staff caring for them to wash their hands — would be ideal for the improvement of handwashing compliance."

Nevertheless, significant improvements in worker compliance with appropriate hand washing were most clearly evidenced after waterless handwashing agents were placed at bedside. Worker compliance was measured in a medical intensive care unit (MICU), a cardiac surgery ICU (CSICU), and a general medical ward. Direct observations were undertaken in addition to counting devices on dispensers containing hand-washing agents. After collection of baseline data, an education program was introduced in a series of inservices in both ICUs. During the third study phase, the waterless hand disinfectant was placed in the MICU with a 1:4 dispenser/bed ratio, and then studied for a second period with a 1:1 dispenser/bed ratio.

After education the worker rates indicated a slightly higher compliance with appropriate handwashing (MICU: 14%/25%; CSICU: 6%/13%). However, counting devices in the general medical ward showed no increase in soap utilization after the patient flyers were distributed.

On the other hand, observations after introduction of waterless hand disinfectant revealed significantly higher rates. The best results were observed with a 1:1 dispenser/bed ratio (before 23%, after 48%). Even at the 1:4 dispenser/bed ratio, compliance improved markedly (before 19%, after 41%).

Bischoff concluded that the cause for the failure of the education program was "a lack of time related to staffing issues" that included some downsizing, he noted.

"Even without any personnel cuts, the demands on health care workers have generally increased, especially in ICUs over the last years," he says. "The lack of time appears to be a real important factor in handwashing compliance. Therefore, offering easy access to a safe and reliable hand disinfectant appears promising in increasing hand-washing rates and prompted our testing of an alcohol-based waterless solution."

High illness acuity and the low socioeconomic status of many patients likely limited the efficacy of patient awareness flyers. The reaction of the patients varied from indifference to "very interested." In general, most patients reacted positively to the program, but there was no control or observation of how often, if ever, they asked health care workers to wash their hands, he explained.

"Critically ill patients are obviously excluded," he says. "Even less acute patients are sometimes limited in their ability to play an active role in this intervention due to other factors such as educational level. That excludes a major part of possible participants. The second aspect is the possibility of negatively affecting the patient/ health care worker relationship. Even if patients are capable of reminding health care workers to wash their hands, they have to express a wish to a person that is at this point in a position as caregiver. One has to consider that there may be resentment to this proactive role, and even finding a fitting patient population cannot be a guarantee for success."

Even though the education/feedback efforts in the study did not succeed, without such efforts the situation could have been even worse, he noted. Hand-washing compliance should be seen as a team effort, he says, noting that it is vital to include all groups of workers responsible for the care of a patient. Rather than receiving a few weeks or months of emphasis, hand-washing compliance must be targeted as a continuous process to avoid reverting to former practices, he notes. In addition, adequate facilities and products for hand washing must be readily available and easily accessible for health care providers.

"There is no magic formula for this problem by installing bedside disinfectant dispensers," he says. "Our study revealed that even with a 1:1 bed/dispenser ratio, hand-washing compliance was approximately 50% — still unacceptably low. It is more likely that a multifaceted approach, including supervision, use of role models, administrative regulations, and technical improvements will be successful."

Reference

1. Bischoff WE, Reynolds TM, Sessler CN, et al. Handwashing compliance by health care workers: The impact of an education and patient awareness program and the introduction of a new hand disinfectant. Abstract K-132. Presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC). San Diego; Sept. 24-27, 1998.

Giving patients proactive role in hand-washing campaign

As part of a hand-washing program at the Medical College of Virginia Campus of Virginia Commonwealth University in Richmond, flyers were distributed to patients that included the following points of emphasis:

• Doctors and nurses are very busy and would appreciate your help in reminding them to wash their hands.

• Many germs, which cause infection, can be passed by hands.

• Hand washing kills germs — protecting you from infections.

• Hand washing is the single most important procedure for preventing the spread of infection to you. So take control of your care by reminding doctors and nurses to wash their hands.

•Simply ask, "Have you washed your hands?" before they examine you and before and after they wear gloves.