I will admit that over the course of my career, I have not always been compulsive about cleaning my hands on the way into and out of each and every patient encounter. My “road to Damascus” moment came several years ago, when I was seeing a child with a hernia in the emergency department. The visit involved not just our team, but some consultants as well. At the end of the visit, the mother found me and said, “Congratulations. We saw six different doctors, and you were the only one to wash his hands.” All I could respond with was, “That’s truly appalling. I’m very sorry for that.” I wish I could have said I didn’t believe it, but sadly, it’s all too believable. Our own audit data show that, while there is variability across types of providers and different settings, as well as over time, as an organization we consistently fall short of our target of 90%, much less 100%. Admittedly we’re not alone. Several studies have demonstrated compliance rates as low as 10%. Still, our performance is disappointing.
I have to admit, I don’t get it. First of all, I owe it to my patients not to transmit germs from one to another. It’s a critical part of patient safety. More importantly, I owe it to myself. Just the thought of the billions of microbes crawling on every surface in our facility is enough to drive me to the nearest sanitizer dispenser. Surely we all understand the importance; it’s not the days when Semmelweiss was trying to convince his colleagues that there was a link between hygiene and puerperal fever.
So what are the barriers? In the past, there were some real issues. Soap and water aren’t as toxic as the carbolic acid Semmelweiss used, but they can be very hard on the skin – I can recall days in the winter when I’d come home from a shift with my hands cracked and bleeding. And sink placement wasn’t always conducive to “washing in” and “washing out.” But with the newer generation of waterless sanitizers, and dispensers galore, it’s far easier for the providers. It’s just not that hard.
Our improvement strategies so far have been focused on education and prompts. There are signs, posters, pins, badge holders, screen savers, etc. If anyone ever noticed them, at this point they are frankly part of the background noise. For a while we tried to empower families and staff to remind providers. Once or twice I’ve seen a parent ask someone to wash their hands, but it’s a rare occurrence. (Several people have put out videos on the importance of handwashing. While amusing, I have to question whether a YouTube clip, no matter how many hits, has ever changed behavior of a large number of people.)
Increasingly, hospitals are becoming more heavy handed in their approach to improving hand hygiene. A recent New York Times article discusses the types of surveillance being used. For example, at North Shore University Hospital in New York, a video camera is activated when someone enters an ICU room. Hand cleaning is observed and monitored (from a video center in India!), and aggregate statistics on performance posted on an electronic board on the unit. As reported in Clinical Infectious Diseases, compliance went from 6.5% to 89%! A less Big Brotherish but high tech approach is used at another hospital, where a radiofrequency tag in each provider’s ID badge communicates with a sensor on the sanitizer dispenser. If the wearer does not clean her hands, the badge vibrates to give a gentle, private reminder.
I’d hate to think that’s what it takes to get health care providers to wash their hands. We all know it’s the right thing to do, and it’s been made as easy as possible to comply with. Perhaps everyone needs to be mortified by a family’s reaction the way I was to imprint it on us. In any case, please – WASH. The infection you prevent may be your own.