Special Advertising Section: Hand Hygiene—Always a Gentleman

By Tom Inglesby

why has it taken so long to instill the habit of washing before and after treating a patient

If we have known that hand hygiene was necessary for patient safety and wellbeing since the 1860s, why has it taken so long to instill the habit of washing before and after treating a patient? Perhaps, as Adam McMullin, vice president and general manager, Hill-Rom IT Solutions, says, “Hand hygiene has been an established practice that unfortunately just didn’t catch on for the first 50 years because a gentleman’s hands were always clean.” And, of course, all doctors are gentlemen. Or were, for the most part, in the 1800s, at least.

But doctors aren’t the only people who visit or treat patients in the modern hospital and they certainly are not all men. So let’s take a quick review: hand hygiene is acknowledged as an important practice, and it is standard operating procedure in all medical facilities. So how can compliance be made universal?

Policy and procedures are, as we know from experience, a place to start. Education and training along with providing the right facilities to comply with those policies is important. Compliance monitoring can show where there is slippage, and cautions can be issued to those found lacking. It is a complex issue with many factors in play.

McMullin’s comment about a gentleman’s hands may have been in jest, but it represents a typical Victorian era paradigm: no one questions a gentleman; certain things are assumed to be true for that class. We don’t have that luxury today if we ever did. Hill-Rom, Batesville, Indiana, has been in the business of supplying hospitals with a variety of equipment since 1929, and today they take hand hygiene very seriously.

“We are in the business of really providing meaningful automation to the clinical environment so that the right things are happening,” he explains. “We can provide corrective insight, in real time, so if the right things aren’t happening, you can rectify the situation.”

In the area of hand hygiene, he says, “When we launched our latest nurse call, we went to a locating solution that was more flexible. Hundreds of sites have the technology for locating people by their badges. What we developed, in concert with our partner, CenTrak Inc., Newtown, Pennsylvania, was technology to go on a soap or sanitizer dispenser that knows who interacts with that dispenser and when. It allows you to know when you’ve gone into a zone where you have a hand hygiene rule, such as “wash in and wash out” of a patient room. It knows that you went into that room; knows that you have a certain, predetermined amount of time to wash your hands, which is configurable—generally about 30 seconds—and if the badge holder doesn’t follow the protocol, has the potential to notify a supervisor to remind a caregiver or other personnel that they are about to miss a hand hygiene event.”

Hill-Rom does more than monitor hand hygiene events; they work to facilitate change management in that critical area. McMullin explains, “Really driving change management in that environment takes a lot of work. It’s shift-by-shift, and there’s no elegant way to drive that. The things that are going to work have to be intuitive or don’t require a change to your work process. By using the badge everyone is already wearing, we don’t require people to do anything that is different. We found, unless you can get right down to specific individuals and/or job roles, you’re going to reach a threshold where your improvement of hand hygiene will tail off.”

St. Joseph Mercy Oakland (SJMO), Pontiac, Michigan, implemented Hill-Rom’s solution and Fabian Fregoli, MD, vice president of quality and patient safety, notes, “The decision was based on the fact it is a very solid company with a long history here at St. Joe’s of providing quality products and quality service. One of the advantages that we’ve had is the reporting system is very robust, and that provided us with a lot of great management tools to help improve our compliance. Our managers were able to identify individuals and help them get to our target. We’ve seen a significant improvement in our compliance with hand washing that’s truly objectified, and we saw a significant reduction in hospital acquired infections on the unit where we piloted the hand hygiene product.”

McMullin adds, “When you look at infections and the needless harm that is caused by them, and you finally have some technology that, combined with the right processes, can help move the needle, you want to implement it. There’s a lot of great change management dynamics that happen when a team, a shift, or a unit see their scores, and they start to reinforce, ‘Hey, team, we just dropped five points in the last 30 minutes.’ That knowledge can be good for an improvement of 20 or 30 points. And then can start to look at other factors: Did they have the wrong patient load? Was the room designed inappropriately? Did they not have enough access to sanitizer? It can all come together.”

The science of hand hygiene compliance continues to evolve year after year. Automated monitoring systems have been introduced, and while these technologies have shown promise and some success, they do not serve as a replacement for a comprehensive infection prevention program. The best solution is a unit-based and C-suite championed effort towards 100% compliance with hand hygiene.

And it’s not just caregivers who need to be cautioned about hand hygiene. Dr. J. Hudson Garrett Jr., PhD, MSN, MPH, CSRN, VA-BC, vice president, clinical affairs, PDI, Orangeburg, New York, goes into more depth, “Critical care patients can serve as vectors for transmission of healthcare-associated infections. Many patients in the critical care setting are non-ambulatory and therefore unable to wash or sanitize their hands on their own without assistance from the healthcare personnel. This being said, patients should be offered hand hygiene as often as indicated, but particularly before eating, after using the restroom, after making contact with contaminated surfaces such as bedside tables, and also after touching linens and patient gowns, etc.”

The patient’s family can also become part of the extended healthcare team. Garrett continues, “They can provide their loved one with hand hygiene and monitor the compliance for hand hygiene of the patient’s healthcare team. In addition, accessibility of the hand hygiene agent is a necessity for proper utilization. This can be accomplished by providing mounted product inside and outside the patient room, and also having a portable solution such as a patient dispensed hand sanitizer pack within reach of the patient for frequent use.”

What procedures are showing the most promise in hand hygiene and monitoring? “It’s really a combined effort between campaigns to improve compliance and also executive championship,” Garrett says. “Hand hygiene is the central element of a basic infection prevention program, and one that transcends across all spectrums of the healthcare delivery system. Facilities that have C-suite championship of the facility’s hand hygiene program tend to produce more positive and sustainable results. One of the typical challenges with hand hygiene is that as soon as the facility reduces the focus on the initiative and moves onto a different initiative, momentum is lost, and staff revert back to bad behaviors. There is tremendous power in having a member of the C-suite take personal accountability for hand hygiene and be the spokesperson for compliance. Healthcare facilities can also engage the patients’ families in improving compliance by serving as healthcare advocates. This approach combined with routine monitoring (whether through manual or automated technologies) will improve the chances for sustainable success.”

In the rush often encountered in the hospital environment, even washing hands can be done in an inadequate manner. According to Garrett, “Many consumers are not aware of the importance of creating friction during the hand washing process. The friction created is more important than the physical antibacterial agent that is used in regards to soaps and body washes. The FDA has recently released a new position requiring justification of claims made by soaps and body washes. Both the Centers for Disease Control and Prevention (CDC) as well as The World Health Organization (WHO) recommend hand washing with soap and water when hands are visibly soiled, but the use of alcohol based hand sanitizers is most common in today’s fast paced healthcare environment. These FDA-regulated sanitizers are very effective in reducing bacteria and other harmful pathogens on the hands of healthcare providers when appropriately and consistently used.”

Hand sanitizers used in healthcare should contain between 60% and 90% alcohol. The use of ethyl alcohol has been proven more effective against viruses and therefore is more common used as an active ingredient. “Because of the serious risk for transmission of healthcare-associated infections within the healthcare environment,” Garrett says, “the CDC recommends the use of these alcohol-based hand sanitizers in healthcare settings when soap and water are not available or when soap and water are not necessary. It is important that consumers understand the mechanism of action for hand sanitizers, including soaps and other agents, and also use them appropriately.”

Having sanitizer near the bedside is a growing trend. Heather McLarney, vice president of marketing at DebMed, Charlotte, North Carolina, agrees. “We’ve recently expanded our product to work with other companies’ dispensers and we’ve also added a new point-of-care dispenser. When we were tracking compliances in some units where the caregivers are stationed at the patient bedside, like in ICU, they were saying, ‘We are cleaning our hands, but we’re cleaning with these pump bottles that are right by the patient’s bed, so we’re essentially not getting credit because we’re not using the ones on the wall.’ Now we’re using point-of-care dispensers and outfitting them with electronic monitoring that allows us to capture that activity, and we’re the only ones that have the ability to monitor hand hygiene activity at the patient bedside or point of care.”

The DebMed system monitors hygiene events electronically by using the dispenser itself. “Our system is a bit different. First, it is a group monitoring system; it doesn’t track individuals. We did that because it makes it much more cost effective than systems that utilize badges that individual staff members wear. Everyone who works in healthcare knows that it’s important to clean your hands, but they’re not doing it as frequently as they should. The best way to insure that is in a positive manner. So giving feedback at the group level rather than singling out individuals helps the team work collaboratively to that goal, and it’s not seen as punitive as individual tagging.”

The basic premise of any electronic monitoring system is that it gives you more accurate data as well as a much larger sample size than direct observation. In the case of the DebMed system, calculations are based on the World Health Organization’s five moments for hand hygiene. McLarney explains, “If staff members are only cleaning hands before and after patient care then it can miss up to 50% of hand hygiene opportunities. We’ve done some research studies with Columbia University where we benchmarked based on the hospital size and type, large or small hospital or a teaching or non-teaching hospital, and then also by unit type. We benchmarked the number of hand hygiene opportunities based on the five moments, and we take that as a starting calculation. Then we customize it to each hospital unit by getting their census feed on an hourly basis so we know exactly how many patients are in that unit as well as their nurse-patient ratio. That is how we calculate the number of times for this type and size of hospital and this type of unit that we would expect to see hand hygiene events.”

How does the system work in the real world? Connie Steed, MSN, RN, CIC, director of infection prevention at Greenville Health System, Greenville, South Carolina, says, “We conducted research to validate the electronic monitoring process and found it to be closer to reality than direct observation. We know that via video monitoring of patient care. The quantifiable benefits we identified relate to a statistically significant reduction in clusters of multidrug-resistant organisms on our main campus. The hand hygiene monitoring is felt to be one of a variety of process changes we have made that has resulted in outcome improvement.  We have also seen reduction in central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia with the use of process bundles with hand hygiene being one of the components. With this system, we can look at the number of activations of soap and alcohol down to the patient room location. If we have a patient with C. difficile, we check to see that soap is the predominant product used by staff. If we find that alcohol is being used, the data is printed and shared with staff.”

At St. Mary’s Health Center, St. Louis, Missouri, Theresa K. Gratton, BSN, RN, CIC, head of the infection prevention section, has found that electronic monitoring of a different sort has improved their compliance rate. “Here at St. Mary’s, we’ve had a really good culture of patient safety and hand hygiene for many years. We’ve worked very hard at that, and we really wanted to get that last few percentages, to get up from around 90% to 100%. I started investigating technology to see if technology would be able to help us close that gap, eliminate some of the heavy-duty resource, eliminate some of the bias, and help to get a better idea of what the actual volume of hand hygiene compliance was in our nursing areas.”

She explains, “We were looking for something that was simple to implement and that would give us true data on what’s going on at the bedside. The system we decided on was from Biovigil.”

Brent Nibarger, chief client officer at Biovigil Hygiene Technologies, Ann Arbor, Michigan, explains their system: “Healthcare workers are issued an individual user key that they actually attach to their hospital ID badge. When they report to duty, they would pick up a base badge from the charging unit, typically at the nursing station. They plug their user key into it. That identifies them to the badge and then for the shift all of the hand hygiene data that’s collected by the badge is digitally tied to that user. Ultimately, when the badge returns to the base station, we take whatever collected data is in the badge and we export it to a cloud-based application where all the data management and reporting takes place.”

The badge is one part of the system; the other is an infrared sensor that is battery-operated and can be placed anywhere in any room, moved as needed, to provide monitoring of the badges in its proximity. As Nibarger says, “When I walk into a patient room, the badge is pinged by the infrared emitter, and that triggers a series of rules. Those rules are set by the hospital, by a designated administrator, and the rules can be different from unit to unit, job category to job category, hospital to hospital, because not everybody has exactly the same policy and procedures.”

He continues the scenario, “When I walk into a room, the badge shows a green status. As soon as it gets pinged it starts to blink flashing yellow. Typically, every 10 seconds it gives off a little audible chirp. If you don’t do anything, the badge would then progress to a flashing red. You might have another 30 seconds before it would advance to a solid red. During this alert mode, all the user has to do is grab some sanitizer, rub it on their hands, wave their hand in front of the badge, and the badge will then go back to green once it detects the presence of the sanitizer on the hands.”

Does it work? “Oh, absolutely,” Gratton declares. “We’ve seen a lot of improvement as far as the volume of hand hygiene observations. We saw an immediate increase to almost 100%. One of the things that I was very, very adamant about is that nurses needed to stay at the bedside. They couldn’t be required to go to a specific dispenser and interact with that dispenser. That they not be slowed down.

“Another thing that’s really wonderful is it’s interactive with the patient and the family members who are in the room. When they see the blinking badge you just have to very briefly tell them, ‘Green is good and red is not.’ They absolutely love the fact that our nursing staff are proving to them that our hand hygiene is as close to 100% as we can possibly get it at the bedside and for their safety.”

In addition to direct care professionals—doctors, interns, residents, registered nurses, licensed practical nurses, and others—housekeeping, pharmacy, catering personnel and other staff members come into contact with patients and have different hand hygiene requirements. Joel Cook, healthcare solutions director at Stanley Healthcare, Waltham, Massachusetts, says, “I think more and more people are bringing out the importance for everyone who comes in contact with a patient to clean their hands. Our focus has been on monitoring and reporting on the hand hygiene compliance of all the clinical staff and ancillary staff. It is just as important that housekeepers comply with hand hygiene as nurses and doctors.”

Stanley has developed a software “dashboard” that gives staff and administrators a view into the hand hygiene compliance rate. “We are now embedding business intelligence in our mobile view platform and have been working on dashboards with customers for hand hygiene compliance,” Cook acknowledges. “At a glance, they can see what the compliance is of staff by role, location, time of day, and by entrance event, exit event—their overall compliance. In kind of the old world of hand hygiene, people had to run a report and look at it and digest it; now they can look at a live dashboard, and then drill down and ask questions.”

To get the data on hygiene events, Stanley uses a technology called an exciter. “Those exciters are little transmitters that basically say, ‘Hi, I’m here.’ We’re embedding exciters inside sanitizer, gel, and soap dispensers. They’re turned off, normally, so that if I just walk up and stand in front of a hand hygiene dispenser, I don’t get credit. If, on the other hand, I put my hand under the dispenser, the motor runs to dispense some soap, gel, or foam, then that powers our exciter.”

The exciter transmits the ID that’s associated with that dispenser to the tracking tag in the staffer’s badge, and that tag “hears” the exciter and then transmits: “I just washed my hands, effectively, at this location.” Cook adds, “Take it a step farther: Because we know where the staff members are at all times, we know that if they were outside, say at the nurse’s station, and entered a patient’s room and washed their hands or had a hand hygiene event that dispensed gel or soap, then that’s considered a wash-in event. Likewise, if they’re known to be in a room and washed their hands, and then are seen to be outside the room, that’s considered a wash-out event, because it’s very, very important to wash both before you have contact with a patient and after you have contact with a patient, or anything in the room that might be contaminated.”

The dashboard can show wash-in event compliance, wash-out event compliance, and total compliance, defined as the person washed both into and out of the room. “Underneath all that is a complex event processing engine that is looking at relevancy,” Cook claims, “because things get quite complicated if you think about a nurse making her rounds. She could walk into patient A’s room, wash her hands, talk to that person, stand in the room for three minutes, wash her hands on the way out, turn the corner, walk right into patient B’s room, and so we have to have that wash-out event in patient A count as a wash-in to patient B. So the complex event processing engine puts all those pieces together and says, ‘Yes, that was meaningful.’ It’s all time based.

“Likewise, if I walk into the room and say, ‘Hey, what do you need?’ ‘Oh, I need some ice,’ and turn around and walk out, that wasn’t a meaningful contact from the point of view of hand hygiene. I don’t get dinged for not having washed my hands. But if I persist in the room long enough for a meaningful contact to have taken place, then I expect to see a correlated wash-in event.”

Whether the facility uses soap, gel, foam, or a combination throughout, it can now be assured of careful and accurate monitoring of hand hygiene events, by job, location, group, or individual through the use of technology, training, and innovation.

Tom Inglesby is an author based in southern California who writes frequently about medical technologies and improvement strategies.