Hand Washing: Time Well Spent
Tuesday, August 5, 2008
One morning on hospital rounds, I saw a physician colleague enter the intensive care unit where a patient lay intubated and sedated. With his hands unwashed and ungloved, the physician palpated the patient's abdomen, scratched his own head and then placed his stethoscope on the patient's chest to listen to his heart. Then he walked to the nurses station, rubbed his nose and entered a note in the patient's chart.
There was nothing unusual about this. Not washing hands scrupulously remains common practice for professionals at most hospitals, even though abundant research shows that it controls outbreaks of infectious disease, reduces transmission of resistant organisms and cuts infection rates among hospitalized patients.
That same day in a public restroom, I noticed a man go straight from the urinal to the door, bypassing the sinks. Unfortunately, that's a common occurrence, too.
Despite recommendations, nearly 60 percent of health-care workers do not wash hands while on duty. Among the general public, according to a Harris Interactive survey conducted last year, 12 percent of women and 34 percent of men do not wash their hands after using a public restroom. Why?
For one thing, rigorous hand washing is time-consuming. Guidelines advise that we first rinse, then soap for 20 seconds, then rinse again for 30 seconds; after this, we paper-dry our hands and turn the faucet off using the paper towel. For health-care workers, the procedure is supposed to be followed before and after every patient encounter. That means two minutes per patient visit, which adds up to an hour for a doctor who sees an average 30 patients a day, and 2 1/2 hours per shift for an ICU nurse. I have yet to find a doctor or a nurse who is so diligent.
In the past few years, the hand-washing exercise has gotten simpler, with the increased acceptance of alcohol-based gels. I enter a patient's room, squirt gel onto my palms from the wall dispenser, then rub the back of my hands, my fingertips and my thumbs as I introduce myself and ask the patient why he or she is there. Then as I exit, I gel my hands again as I ask, "Do you have any questions?"
Despite the ease of using alcohol gel, studies show that nearly a quarter of health-care workers do not regularly disinfect their hands. Few realize that our bodies are like petri dishes teeming with 300 trillion organisms and that our hands are like swabs for the transmission of antibiotic-resistant bacteria such as MRSA, pseudomonas and C. difficile.
What can we do to improve hand-washing rates?
First, we must admit that the "Just do it!" approach of the past 150 years has failed. Behavioral theory tells us that changing behavior in a change-resistant culture cannot be accomplished with a single intervention.
We need a carrot-and-stick approach. Let the carrot be a campaign of incentives and awards for hand washers, similar to the eat-more-vegetables campaigns that many parents conduct with their children.
Then we need the stick. Health facilities need to monitor the hand-washing rate for each unit and provide feedback and improvement strategies to health workers at the bedside. Observers need to be stationed in ICUs and hospital wards, much like traffic cops at the bottom of a hill. Repeated failures to comply, as in the case of my physician colleague, would result in a letter to the offender and a note in his credentialing file or employment record.
Hospital administrators, not just their staffs, also need a stick over their heads. Starting in October, hospitals will be penalized for the consequences of unwashed hands: Medicare will no longer pay for complications arising from certain hospital-acquired infections, which in many cases result from poor hand hygiene. This will be a powerful incentive for health executives to improve hand-washing compliance.
An aggressive approach to hand washing has worked. At the University of Geneva, a hospital-wide program promoting hand hygiene helped lower the hospital-acquired infection rate from 17 percent to 10 percent between 1994 and 1998.
At Novant Health hospitals in Charlotte and Winston-Salem, N.C., a 2005 hand-washing campaign -- complete with billboards and computer screen savers -- brought about a sustained drop in MRSA and hospital-acquired infections. At Reston Hospital Center, an awareness campaign introduced in 2006 has boosted hand-hygiene compliance to more than 90 percent; it also led to a drop in the hospital's infection rate.
A 2007 study from John Hopkins showed that using simple checklists as reminders about basic hygiene such as hand washing and about proper draping, gloving and masking reduced the central intravenous line infection rate by 66 percent in ICUs.
About my physician colleague: I approached him and gently reminded him. "The patient likely has resistant bacteria -- it is really important that we wash our hands after every encounter." Suddenly self-conscious, he groped for the alcohol gel dispenser just a few feet away.
As for the man in the public restroom: I'm sure that I got his germs on my hands from the door handle.
Manoj Jain is an infectious disease physician in Memphis and a medical director of Medicare's quality improvement organization in Tennessee. Comments:firstname.lastname@example.org.