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ED Crowding Detrimentally Affects Hand Hygiene Among Staff

TORONTO – When the emergency department is packed with patients, clinicians barely have time to breath. So, it should come as no surprise that handwashing rates also are affected.

What might be shocking, however, is how low the hand hygiene rate can drop among physicians when ED crowding occurs.

A study published online recently by the journal Academic Emergency Medicine sought to determine how much ED crowding affected the rates of hand hygiene among healthcare workers.

To do so, a trained observer measured hand hygiene compliance for 22 months in the 40-bed ED of a 475-bed academic hospital in Toronto. The study team, led by researchers from St. Michael’s Hospital, also compiled ED crowding measurements, including mean daily patient volumes, time to initial physician assessment, and daily nursing hours. Hand hygiene data, measured during 20-minute observation sessions, then were linked to aggregate daily results for each crowding metric.

Overall, hand hygiene compliance was found to be 29% –325 of 1,116 opportunities – with alcohol-based hand rinse used 66% of the time. Nurses accounted for 68% of hand hygiene opportunities and physicians for 18%, with other staff having even lower rates.

Results indicate that the most common indications for hand hygiene were hand hygiene prior to (35%) and hand hygiene following (52%) contact with the patient or his or her environment. Compliance was lower when time to physician assessment was more than 90 minutes. Daily patient volumes and nursing hours were not associated with hand hygiene compliance.

“Strategies that minimize ED crowding may improve ED hand hygiene compliance,” the authors suggest.

Another study, published recently in BMJ Quality & Safety, finds that the time bind in a crowded ED is not the only constraint. In an observational study, Columbia University researchers found other environmental factors at play, such as having patients overflowing into hallways.

From October 2013 to January 2014, trained observers recorded hand hygiene compliance among staff in a single ED according to the World Health Organization ‘My 5 Moments for Hand Hygiene’.

With 1,673 hand hygiene opportunities observed, hand hygiene compliance was significantly lower when the ED was at its highest level of crowding than when the ED was not crowded. It also was lower among hallway care areas than semiprivate care areas.

“Unique environmental conditions pose barriers to hand hygiene compliance in the ED setting and should be considered by ED hand hygiene improvement efforts,” the authors conclude. “Further study is needed to evaluate the impact of these environmental conditions on actual rates of infection transmission.”