Health care's dirty little secret - Progress notes

Throughout their training, health care workers are drilled to wash their hands thoroughly and correctly, and we would like to think they all heed the lessons. But several studies, including two observations at Texas Children's, show this is not the case.

Texas Children's is implementing several new initiatives to improve hand hygiene. These include:

A physician task force organized through Medical Staff Services
A system-wide hand hygiene task force
Education of health care workers
Education of patients and families
Awareness campaign throughout IDS
Incentives and enablers

Widespread laxity in hand washing compliance in the health care industry is set against a backdrop of an alarming increase in hospital-acquired infections, which cost hundreds of lives and millions of dollars each year. To remedy this, Texas Children's is introducing initiatives to increase the rate of hand washing and decrease hospital-acquired infections.

Check the numbers

At an Infectious Disease Society of America conference a few years ago, two medical students observed the attendant's hand washing behavior in the restrooms. Thirty percent of women and 70 percent of men did not wash their hands adequately.

Closer to home, a Texas Children's infection worker in 2004 directly observed health care workers on various wards. Using a standardized form and number of observations, the surveyor watched each health care worker during the entire hand washing opportunity. Total house-wide hand hygiene compliance was 62 percent, with a high in BMT of 91 percent and a low of 41 percent in 11WT. Looking at the figures by type of worker, respiratory staff was the most compliant at 83 percent, nurses were second at 73 percent, and doctors lagged at 60 percent.

Another Texas Children's observation, which included data collected over five consecutive days in October 2006, examined whether health care workers washed their hands at specific, designated opportunities for hand hygiene. The total compliance was just over half, with 245 of the 483 health care workers following correct procedures. This included 45 percent of doctors and 52 percent of nurses.

Get past the roadblocks

Health care workers have plenty of reasons – or, more accurately, excuses – for not washing their hands. But there are even more reasons why they should.

Excuses range from "I don't like the soaps that are available" to "I forgot" and "I have on gloves." Some of the most common reasons for not adhering to hand hygiene rules include:

Hand irritation and dryness
Inconveniently located sinks and cleaner dispensers
Lack of time
Interference with health care worker-patient relationship
Skepticism of the value of hand hygiene
Low institutional priority

But hand hygiene is crucial for a host of good reasons. Nosocomial infections are the fourth-leading cause of death in the United States, causing or contributing to some 100,000 deaths per year. In addition, state and public reporting of infection rates is now mandatory. The Center for Medicare and Medicaid (CMS) will not reimburse for certain healthcare-associated infections, e.g. vascular catheter-associated infection, and private companies soon will follow. And 100 percent compliance with hand hygiene guidelines is a JCAHO patient safety goal.

Method and materials matter


	Hand hygiene preparations Non-antimicrobial soap Chlorhexidine Parachlorometaxylenol [PCMX] Hexachlorophene Iodine and iodophors Quaternary ammonium compounds Triclosan Alcohols

So the issue should not be whether, but when and how to wash. The CDC's latest guidelines, released in 2002, recommend:

If hands are visibly soiled, clean them with a non-antibacterial or antibacterial soap and water.
If hands are not visibly soiled, use an alcohol-based hand rub for routine decontamination.

Alcohols at more than 60 percent concentration are germicidal against gram-positive and gram-negative bacilli, most enveloped viruses (RSV, HIV, HSV) and some nonenveloped viruses (rotavirus, adenovirus, rhinovirus, enterovirus). They have poor activity against bacterial spores (C. difficile), protozoan oocysts and some nonenveloped viruses (norovirus).

Hand hygiene using alcohol foams or gels is superior to other forms of hand hygiene, especially in busy clinical settings, and alcohol-based handrub is less damaging to the skin than soap and water. However, alcohol effect is not persistent, so frequent use is necessary.

Getting everyone on board

How can we promote hand washing? The keys are education, motivation and system involvement. This includes education of health care workers, volunteers, patients and families; engineering the hospital environment so hand washing is convenient; administrative sanction and reward; and avoiding overcrowding and understaffing. An overall improvement in institutional safety climate helps as well.

Texas Children's is working to address hand washing compliance with a number of wide-ranging initiatives. Involvement of the medical staff is mandatory as we move forward with our plans.

Jeffrey R. Starke, M.D., is director of Infection Control at Texas Children’s and professor and vice chairman of Pediatrics at Baylor College of Medicine.

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