It is surprising that in the year 2011 we have not yet mastered the task of hand washing. In 1843, Dr. Oliver Wendell Holmes was advocating hand washing to prevent disease. In the 1850’s Florence Nightingale demonstrated the effects of cleanliness on patient outcomes during the Crimean War. According to the Centers for Disease Control, “Hand washing is the single most important means of preventing the spread of infection.”
Poor Hand Hygiene Compliance
So, why do we still have such poor compliance with a problem that has such a simple solution? I have read reports that had reasons ranging from dry, irritated hands, sinks that are not in a convenient place, staffing shortages, and healthcare clinicians just being too busy to wash their hands. With many clinicians, there are probably several other reasons that they use to justify not following their hospital’s policy to the letter. One thing is clear: it is not the habit it should be with all employees of a hospital. I have thought that hand hygiene is similar to seatbelts, but it’s just not a habit yet. Think of a hand hygiene solution like the reminder that you haven’t put on your seatbelt. I never hear the reminder now - I just always wear my seatbelt.
What should we do? If we are infecting two million patients annually resulting in approximately 100,000 deaths and costing billions of dollars to a stressed system it is clear that we need to do something different now!
Objective Surveillance
This is where objective surveillance comes in. The problem to date has been the cost and inefficiency of people monitoring people. Hospitals who have tried this have received statistically significant increases, but the compliance is still not where it needs to be for patient safety. There are just too many hand washing opportunities to make manual observation efficient and effective.
Using Healthcare IT to Monitor Behavior
This is where technology steps in. With the ability to monitor the events and non-events of each clinician, there is now the ability to promote change and compliance. For the users who have not made hand washing a habit, these systems give the reinforcement needed to make a permanent behavior change. For clinicians that have not made it a habit, technology will reinforce the desired behavior. For the minority who consciously think hand washing is not important, this will give the hospital data to enforce the desired behavior. Clinicians are aware they are being monitored 24/7 by a system that has no political bias and does not show favoritism. It yields data to drive performance improvement by infection control and hospital leaders. And, this is a way to take a misstep and turn it into a learning opportunity.
This process will only have the desired effect if it is part of a larger hospital-wide initiative and process. Technology alone will not solve the problem. It will however, provide the needed information to address the issues and change behavior. Staff needs to see where the hand washing solution fits in the overall infection control process and its effect on patient safety. Deploying a solution makes the statement that hand washing is an important value to the hospital.
What Needs to Happen
What does this system need to do? It needs to monitor hand sanitizer and soap and water. There is not a one-size-fits-all hand washing event, so the technology selected needs to be able to handle different solutions. It should also be able to handle the possibility that alcohol will not always be the best component for hand sanitizers.
One school of thought is that you have to prove you washed your hands by having them sniffed. Alcohol on the hand does not mean that someone took 20 seconds to thoroughly get the gel spread all over the hand. It only shows that there is alcohol on the hand and it could be from an event from the previous room that you just visited. The argument then falls apart even more when these same units need to monitor hand washing with soap that does not contain alcohol.
In surgery, we always promoted what we called a surgical conscience. A conscience that said I contaminated something that no one else saw me do, but I am going to let everyone know anyway. I believe most clinicians have a surgical (clinical) conscience and if they are reminded to wash their hands and start the process with gel or soap, they will complete the process appropriately.
Other Considerations
Are there any other considerations? I would argue that using solutions to only address hand washing opens up the possibility that your clinicians will look like a general on a battlefield with tags for ID, workflow, and hand washing hanging from their pocket. An awareness system is the appropriate choice because you can tie in events to the workflows and assets and not treat hand washing as a complete stand-alone process.
There are three key elements that need to be addressed on this topic:
1. Create a system/environment of compliance that supports all types of hand washing events.
2. Ease of implementation in a complex and sensitive work environment.
3. Make it part of an overall awareness system as opposed to a stand-alone system.
And not to leave out the obvious, how about a system that is easy to use?
~Thomas Hamelin, R.N.
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