Challenging Dogma - Fall 2008

Thursday, December 18, 2008

Hand Hygiene Interventions Need Some Cleaning Up: A Critique of Current Hand Hygiene Program’s in Hospitals Nationwide - Emily Scheer

Hospital acquired infections (also known as nosocomial infections) are a well documented cause of increased morbidity and mortality among hospitalized patients in the United States. Nearly 2 million patients are affected and almost 80,000 individuals die each year as a result of acquiring such infections making this a serious public health issue in the United States (4). Given the severity of this issue, successful public health interventions are necessary to halt the spread of disease.
Hand hygiene has been identified as an essential evidence based infection control measure to prevent the occurrence of hospital acquired infections, “Hand hygiene by hand washing or hand disinfection remains the single most important measure to prevent nosocomial infections” (9). Nonetheless, hand hygiene policies are not always followed by health care workers and poor compliance is repeatedly documented throughout entire hospitals and hospital systems nationwide. Some interventions have proven successful. However, success has been short lived. Hand hygiene programs in the United States have had difficulty achieving lasting improvement (4). If hand hygiene interventions fail to incorporate a multidimensional approach to behavior change, social norms and self efficacy, and continue to be unsuccessful in effectively educating health care workers, successful hand hygiene programs cannot be sustained.
Lack of an Interconnected Approach to Behavior Change

What many widespread hand hygiene interventions are missing is a multi faceted and creative design to change health behavior (4). Interventions aimed at improving compliance with hand hygiene must be based on the various levels of behavior interaction including the interdependence of individual factors, environmental constraints such as access to hand washing supplies at point of care, knowledge and values that are inherent to the many medical specialties, and institutional culture. Noncompliance with hand hygiene interventions may not only relate to the individual health care worker but to the group or specialty he/ she belongs to.
The complex dynamic of behavioral change involves a combination of education, motivation, and system change that acknowledges social norms and self efficacy. Hand hygiene interventions have traditionally followed the framework of the popular and frequently utilized model of health behavior, the Health Belief Model (3). This model focuses on behavior change at the individual level. It is limited in that it does not look at change in a group context nor does it account for social and environmental factors. Time after time, hand hygiene guidelines focus on the individual and fail to incorporate aspects of the complicated environment that the typical health care worker is in. Many risk factors for non-compliance with hand washing among health care workers are continuously faced including increased workload, stress, lack of time, psychology, the culture of the environment or unit of the hospital, individual values as well as values inherent to certain medical specialties, availability and access to hand washing materials, type and intensity of patient care required, nurse to patients ratios, and education as to what the correct hand-hygiene techniques are (9). Compliance with recommended instructions is commonly poor because hand hygiene models have failed to consider and account for these complex risk factors. Hand hygiene interventions have primarily focused on the individual which is not enough to result in sustainable change (7).
Failure to Establish a Culture of Safety that Incorporates Social Norms and Self Efficacy
Traditional hand hygiene interventions have failed to consider social norms in development of policies. In health care, as in many other environments, behavior will be influenced according to whether or not a person will meet approval or disapproval by his/her social groups, or in this case among the various medical specialties (nursing, physicians, respiratory, etc) (3). For example, if the intervention is driven by the nursing department, a physician may be less likely to comply because his/her group did not “buy in” to the program. The physician-in-chief did not support the program or feel that it was necessary and this attitude and belief trickled down to the rest of the physicians. Hand hygiene interventions must incorporate social norms and above all aim to make compliance the social norm among all medical specialties.
An additional limitation of current hand hygiene programs is the lack of incorporation of self efficacy. Staff must believe that they have the ability and power to make major improvements and that hand washing will lead to these big improvements. Health care workers must be empowered to remind other caregivers, regardless of rank, position, or specialty to practice hand hygiene and comply with all guidelines (4).

Failure to Educate and Communicate
A key element in implementing a successful hand hygiene program is educating and motivating the staff. Unfortunately, hand hygiene interventions based on the Health Belief Model assume that all health care workers have enough education and knowledge to make a rational decision surrounding hand washing. In reality, there is an overall lack of knowledge among health care workers regarding how hands are easily contaminated, how infection is spread, the efficacy of hand hygiene in reducing this spread, and lack of awareness of the recommended and most effective hand-washing techniques (8). The Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee published Guideline for Hand Hygiene in Health-Care Settings in 2002. Within these guidelines, it strongly recommended that alcohol-based hand rubs are the preferred method of hand hygiene because they are easy and quick to use and are extremely effective in killing bacteria and viruses that cause nosocomial infections. Introduction of alcohol-based hand rubs and education materials must be introduced as a part of hand hygiene programs and spread at a group level. Hospital employees need to be able to express knowledge and understanding that alcohol based hand rubs are extremely effective, are accessible, and are very quick and easy to use. Current hand hygiene programs have failed to ensure that staff entirely comprehend the rationale behind implementing hand hygiene programs. They are not designed in a way that results in high levels of staff “buy in” and high staff comprehension of the danger of not complying with the policies, not only to their patients but to themselves (2).
When asked, health care workers report the following reasons that they believe make it difficult to comply with hand hygiene programs: skin irritation caused by constant washing or use of the disinfectant rubs, “being too busy”, and “not thinking about it” (9). Health care workers must be educated that alcohol-based hand rubs have advantages to traditional hand washing because they require less time, are extremely fast acting and effective in preventing transmission of infection, and are less irritating to the skin. Studies have found that alcohol based hand rubs do contribute to the sustainability of high program compliance rates and are associated with decreased infection rates (7).
The Future of Hand Hygiene
Traditional hand hygiene programs may be successful short –term in some hospitals as an effective way to reduce hospital acquired infection rates but this intervention is not likely to be both effective and sustained for long periods of time. A more appropriate hand hygiene intervention would focus on health care worker’s behavior at the group level. Hand hygiene programs must be further developed to move beyond a model that focuses on individual behavior and include more psychosocial elements that will influence intention, attitude toward the behavior, perceived social norms, perceived risk of infection for self and patient, habits of hand hygiene practices, knowledge, and motivation at both the individual and group level. (7) Interventions must grow to incorporate a multidimensional approach to behavior change, social norms and self efficacy, and figure out how to effectively educate health care worker. Until then, morbidity and mortality due to hospital acquired infections will remain high in hospitals across the United States. Hand hygiene interventions must be changed so that quality of life can be improved for millions of patients in this nation’s health care system.
Hand Hygiene Programs in the United States: All Cleaned Up!
An unfortunate reality for the current health care system in the United States is that the prevalence of drug-resistant organisms in nosocomial infections is high and continues to be on the rise. The impact that this has on patient outcomes is incredibly severe. In light of all of this, it is well documented that prevention is possible. The key intervention suggested and supported by endless evidence is surprising in that it seems so simple. It is something that many of us were taught to do regularly since we were fairly young – wash our hands (7)! Although evidence based, proven important, and simple sounding, “hand hygiene by hand washing or hand disinfection remains the single most important measure to prevent nosocomial infections,” (9) hand hygiene interventions have been complicated and difficult to implement and sustain. Experts estimate that health care workers comply with recommended hand hygiene procedures less than 50 percent of the time — contributing to some terrible consequences (7).
Due to increased morbidity, mortality, and health costs that can result from health care workers failing to comply with hand hygiene protocols, this has become a major public health problem in the United States. Clearly, it is an issue that is worth working on and devoting substantial resources to. An alternative program must be implemented nationwide that moves away from policies based on the traditional health behavior models. A new program should incorporate an interconnected approach (specifically dealing with the health care environment and access issues), social norms, messages of empowerment and self efficacy, and improved education and communication of vital information.
Incorporating an Interconnected Approach to Behavior Change
An improved hand hygiene model should concentrate on taking an interconnected approach to improving compliance with hand hygiene programs. Unfortunately, many current hand hygiene programs currently take an “x causes y” approach to forming new policies and dealing with the issue. This type of approach does not deal with the “messiness of life.” Major risk factors for poor compliance with standard policies include lack of time or opportunity and poor access to hand washing facilities (7). These risk factors move beyond individual behavior and indicate that there are many external factors that can make behavior and life “messy” at times. This indicates that to implement a sustainable program these factors in the environment of the health care worker must be acknowledged.
In an ICU setting there is high workload and high demand of care. To improve access, opportunity, and deal with time constraints, the main hand hygiene agent promoted should be an alcohol based hand rub because it is quick to use, easy to access, and highly effective. Here, a focus study should be done with staff that examines various locations of the gel dispensers to ensure best possible access. The dispensers should be trialed at different locations at the bedside to determine where they are most easily accessed and most often remembered and used. Another proposal to improve access is to look at where health practitioners already keep items and information they want to have immediate access to. For example, many physicians keep tools the need to use in their white coat pockets such as patient notes, calculators, blackberries, etc. Leading alcohol based hand rub manufacturers have developed smaller and slightly flatter bottles. These could easily be stored in physician’s pockets without getting in the way. This would make hand hygiene available right at his/her hip in a location that is easy to remember and already part of their culture and behavior.
Establishing a Culture of Safety that Incorporates Social Norms and Self Efficacy
One major critique of current hand hygiene interventions is that they have traditionally followed the framework of the popular Health Belief Model (3). As mentioned previously, this model focuses on behavior change at the individual level instead of in a group context. It does not account for social and environmental factors. A hand hygiene program that changes focus to an alternative health behavior model that values and emphasizes social norms, such as Social Norms Theory, would prove to be a more successful and sustainable intervention. Social norms theory states that the behavior of an individual is greatly influenced by the way they perceive behavior of his/her social group (1). In the health care environment, if the worker views his/her medical specialty as being non-compliant with hand hygiene interventions, the urge that individual may feel to conform to that idea will negatively impact the compliance behavior of that entire group or specialty. However, if the various health care groups are educated effectively and hand hygiene is framed in ways that portray it as the norm and supported practice of the group, there may be more overall “buy in” to the program which would result in an overall higher compliance rate for the specialty group as well as the entire unit. Parallel to that, nosocomial infection rates and associated health costs would hopefully decrease.
Developing a culture of empowerment would help to foster compliance and change the social norm. There is an inherent hierarchy in the medical setting among the various specialties. Work should be done to eliminate this hierarchal structure and ensure that, for examples doctors and nurses feel that they are on the same level and have the same worth in influencing care of their patient. The feeling of empowerment developed by each group would trickle down to the individual and help him/her to be an advocate for a patient’s safety by kindly reminding his/her colleague to comply with hand hygiene policies. Hand hygiene is something that has to be practiced at every opportunity in order to get positive results. Therefore, self efficacy is an important component to any hand hygiene program. If health care workers believe that they have the ability and power to make major improvements by completing the simple task of washing hands per policy, compliance rates may rise. The action must be promoted as one small piece of a giant puzzle that makes up this major improvement.
Implementing Widespread Education and Communication
Many current hand hygiene programs have incorporated some type of education about hand hygiene through poster display or leaving pamphlets in staff mailboxes. However, merely making the poster is not an improvement and it is not adequate education and information. Instead, all efforts must be focused on placement and use of the poster. Posters should be informative, captivating, and placed in locations where they will not be missed (on the door to the unit, at the front desk, in the bathrooms, etc). Focus group should be formed by quality improvement staff and surveyed to assess whether or not people report noticing it, whether staff can answer questions about the material on the poster, and to ask people directly whether they believe it worked or not. The poster can be tested in various locations of visibility on the unit. Once the most ideal location is decided upon based on focus group feedback, information should be changed in and out on a regular basis to update, inform, and reeducate staff. To enhance communication, improvement leaders should make sure that data and audit results are disseminated to staff and posted where it can be seen. In many widespread surveys, health care workers report that they don’t see the numbers or results they just get the order to “do better” and this does not make them happy. Health care workers need to be made aware that hands need washing in certain situations. They should be educated on the specific definitions of hand hygiene “opportunities”, what supplies are available to them, and the location of such supplies. A hand hygiene program should identify and educate a few “champions” from each medical specialty who will go through training and evidence based education sessions. Each champion would be responsible for educating his/her appropriate group and advocating for change (5).
Education and communication also goes beyond the health care practitioners. A successful hand hygiene program should have a patient and visitor component, as well. A patient/visitor educational brochure and program should be developed that includes an orientation to the unit’s policies on hand hygiene and the negative outcomes that can occur as a result of failed compliance by health care workers. This will ensure that patients and families are aware and empower and encourage them to remind health care workers to wash their hands when caring for the patient (5).
It is clear that a hand hygiene intervention that focuses on health care worker’s behavior at the group level will be successful and sustainable. Hand hygiene programs must move beyond a model that focuses on individual behavior and acknowledge that noncompliance with hand hygiene interventions may not only relate to the individual health care worker but to the environment and group or specialty he/ she belongs to. Therefore, a proposal to improve hand hygiene must incorporate the main attributes of social norms theory in order to make effective and sustainable change within hospital systems in the United States. It must also focus on access and environmental issues and utilize innovative education techniques. Overall, hand hygiene program designers and implementation managers must truly try to understand what really motivates people, specifically the medical staff in question, and work to gain better understanding of human behavior.
1. Best Practices; Social Norms.
2. Boyce JM, Pittet D, et al. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity Mortality Weekly Report, 2002.

3. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

4. How-to Guide: Improving Hand Hygiene. Institute for Healthcare Improvement. 2006.

5. Institute of Health Care Improvement. Improving Hand Hygiene Practice with Six Sigma. St. Paul, MN: HealthEast Care System.
6. Institute of Health Care Improvement. The Sound of Two Hands Washing: Improving Hand Hygiene.
7. Pittet, D. Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infectious Diseases 2001.

8. Pittet D, Boyce JM. Hand hygiene and patient care: Pursuing the Semmelweis legacy. Lancet Infect Dis 2001.

9. Pittet D, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet 2000.
10. WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary. World Health Organization, 2005.

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