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No one ever enters the sterile field of the operating room without first scrubbing his or her hands. But how can you get other staff to place a similar importance on basic hand washing between patient encounters? Researchers say two steps can lead to better hand hygiene: One step is complex, and one is simple. The organizational climate, led by hospital administration, needs to make hand hygiene a priority.1 And the use of alcohol-based gels in convenient dispensers can reduce skin irritation and improve compliance.2
Trying to change behavior one unit at a time can be frustrating, or even futile, asserts Elaine Larson, RN, PhD, professor at the Columbia University School of Nursing in New York City and an expert on hand hygiene. "I think the trick is taking a systems approach rather than trying to work on individual change," she says. "It takes the blame out of things. The whole organization expects this behavior from you, and it’s the norm. Then I think people are much more likely to change. If they think their peers are going to be doing this, then they are as well."
The strongest way to emphasize hand hygiene would be to include it in employees’ performance evaluation. But that is not the only way to impress upon staff that consistent hand washing is a vital part of their jobs, says Larson. "The difference isn’t so much the specific strategies you use as it is the very strong administrative involvement."
In her study of organizational climate change, Larson began by meeting with the hospital’s chief executive officer, vice president for nursing, hospital board, and medical staff board. A team of about 20 managers held brainstorming sessions and developed the interventions. The team began with an open letter from the CEO to all employees, volunteers, and physicians emphasizing the commitment to hand washing and to the proposed intervention. It also sent out fact sheets on hand washing and conducted educational programs.
The strongest element, however, involved a new competency-based practice. All employees were required to demonstrate their competency in hand hygiene before they could provide patient care. That requirement remains for all new employees, as well. "If you’re trying to change a very inbred practice, you’ve got to make it look different than it did before," says Larson. "You can’t just have an infection control nurse going around telling people to wash their hands. It’s totally worthless, in and of itself."
Using counters hidden inside soap dispensers, Larson and her colleagues counted significantly more hand-washing episodes at the intervention hospital than the control hospital. At a six-month follow-up, hand washes per patient care day were double that of control. Meanwhile, nosocomial infections with vancomycin-resistant enterococci were significantly lower at the intervention hospital.1 "Nothing’s going to work unless there’s this climate change," says Larson. "Even with that, there have to be multiple interventions, even if they’re small. The staff have to believe that their bosses really value this practice."
Even simple interventions work better from the top, down, says Larson. "The strategies [the managers] suggested, we have tried and they didn’t work," she says. "They didn’t work before because they weren’t coming from the bosses."
To achieve sustained change, hospitals also must be prepared for long-term support of the interventions. At three Minnesota hospitals, a study found that a multidimensional intervention with education, reminders, and role modeling by unit heads resulted in short-lived improvements.2
"We did see a significant increase in adherence, up until about 50 to 60 days," says Carol O’Boyle, PhD, epidemiology supervisor at the Minneapolis Health Department. "At about two months, we began to see that it reverted to baseline. You need six months of support before [a task] is incorporated into their behavior."
At the University of Utah Hospitals and Clinics in Salt Lake City, continuous feedback based on observation of hand hygiene helped employees boost their compliance rates.3 A monthly "Golden Hand" award created competition that inspired units to improve their hand hygiene, says Adi Gundlapalli, MD, PhD, a third-year fellow in infectious diseases at the University of Utah School of Medicine who coordinated the yearlong project.
The feedback also was very visible. For example, graphs showing how units fared on hand hygiene were placed in the employee bathroom of the medical intensive care unit — where everyone was sure to see it. Perhaps the most effective intervention came from the unit that chose hand hygiene as a pay-for-performance project. Their goal was 70% compliance, a rate the unit exceeded, Gundlapalli says.
The challenge now will be to provide periodic observation and feedback on hand hygiene, even after the project is completed, says Barbara Mooney, RN, CIC, coordinator of hospital epidemiology at the University of Utah. "As infection control people, we have to sustain the effort," says Mooney. "We can’t say we’ve done this, and move on. This will be something that’s too important to let go."
Meanwhile, studies continue to show the potential impact of using alcohol-based gels instead of soap and water. Both O’Boyle and Gundlapalli found a high level of acceptance of the gel product. The gel can eliminate or reduce skin irritation due to washing, which is one reason for diminished hand hygiene, experts say. In fact, while Gundlapalli limited his project to four units, other hospital departments independently bought the gel and began using it, Mooney says. "It’s very successful for them also, although they’re not a part of the project," she says.
Swiss researcher Didier Pittet found numerous factors that contribute to poor hand hygiene, including heavy workload, understaffing, lack of administrative leadership and support, and lack of adequate hand hygiene agents.4 Although it can’t address all the problems that lead to poor hand hygiene, alcohol-based gel can improve compliance, Pittet found. "[E]asy and timely access to hand hygiene . . . and the availability, free of charge, of skin care lotion, both appear to be necessary prerequisites for appropriate hand hygiene behavior," he concluded.
1. Larson EL, Early E, Cloonan P, et al. An organizational climate intervention associated with increased hand washing and decreased nosocomial infections. Behav Med 2000; 26:14-22.
2. O’Boyle C, Henly SJ, Vesley D. Multidimensional intervention for adherence to hand hygiene recommendations: Immediate and long-term impact. Presented at the 2001 annual meeting of the Society for Healthcare Epidemiology of America conference. Toronto; April 2001.
3. Gundlapalli AV, Mooney B, Eutropius L, et al. A multi-dimensional intervention to improve hand hygiene compliance: Preliminary results. Presented at the 2001 annual meeting of the Society for Healthcare Epidemiology of America conference. Toronto; April 2001.
4. Pittet D. Improving adherence to hand hygiene practice: A multidisciplinary approach. Emerg Infect Dis 2001; 7:234-240.