Hand Hygiene: The First Defense Against HAI

by Don Sadler

OR Today Magazine | Cover Story | January | Hand Hygiene

The statistics regarding healthcare associated infections (HAIs) are truly frightening: The Centers for Disease Control and Prevention estimate that two million patients get an HAI while in the hospital each year, and 99,000 of them die as a result of the HAI. The financial cost of HAIs to hospitals is an estimated $45 billion annually.

Often, hospitals think that their hand hygiene compliance rate is above 90 percent, but whne it’s measured using the specific criteria of the TST, it’s approximately 45 percent. Participating hospitals that have used the TST have increased this to over 80 percent. – Dr. Erin DuPree, MD. Chief Medical Officer and Vice President with the Joint Commission Center for Transforming Healthcare.

“The hand hygiene TST focuses on improving and sustaining hand hygiene compliance,” says DuPree. “It is a guided tour of rigorous methodology that makes it easy for hospitals to figure out what are the determining causes of less-than-stellar hand hygiene. The TST provides the foundation and frame-work of a method that will improve a hospital’s hand hygiene compliance when implemented properly, and contribute substantially to its efforts to reduce the frequency of HAIs.”

As shocking as these statistics are, the solutions to preventing HAIs are relatively simple. At the top of the list is for healthcare workers to practice proper hand hygiene procedures.

OR Today | Magazine | January| Quote Hand Hygiene“Hand hygiene and surgical hand antisepsis are the foundation of infection prevention for all perioperative personnel,” says Dr. Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR, the Director of Evidence-Based Perioperative Practice for the Association of periOperative Registered Nurses (AORN). “Hand hygiene practices can jeopardize safety in the perioperative area if they are not performed as recommended.”

“Hand hygiene is basic clinical care, but it’s paramount to providing the best care possible for patients,” adds Dr. Erin DuPree, MD, Chief Medical Officer and Vice President with the Joint Commission Center for Transforming Healthcare.

A Complex Problem

The failure of many healthcare workers to practice proper hand hygiene techniques, DuPree notes, “is a complex problem that isn’t easy to solve. A simple slogan or campaign isn’t enough, nor is demanding that healthcare workers try harder. Comprehensive, systematic and sustainable change is the only solution to the problem.”

To this end, the Joint Commission Center for Transforming Healthcare has developed the Targeted Solutions Tool (TST) to help tackle difficult problems like hand hygiene failure. The TST is an application that guides healthcare organizations through a step-by-step process to accurately measure their actual performance, identify barriers to excellent performance, and direct them to proven solutions that are customized to address their particular barriers to proper hand hygiene techniques.

“The hand hygiene TST focuses on improving and sustaining hand hygiene compliance,” says DuPree. “It is a guided tour of rigorous methodology that makes it easy for hospitals to figure out what are the determining causes of less-than-stellar hand hygiene. The TST provides the foundation and framework of a method that will improve a hospital’s hand hygiene compliance when implemented properly, and contribute substantially to its efforts to reduce the frequency of HAIs.”

The Joint Commission Center for Transforming Healthcare discovered that there is a big disconnect between what hospitals think their hand hygiene compliance rates are and what they really are when measured accurately.
“Often, hospitals think that their hand hygiene compliance rate is above 90 percent, but when it’s measured using the specific criteria of the TST, it’s approximately 45 percent,” says DuPree. “Participating hospitals that have used the TST have increased this to over 80 percent.”

In developing the TST, the Joint Commission Center for Transforming Healthcare identified a number of different causes of hand hygiene failure, including:

  •  Ineffective placement of hand sanitizer dispensers or sinks.
  • Ineffective placement of hand sanitizer dispensers or sinks.
  • Lack of accountability and just-in-time coaching.
  • A safety culture that does not stress hand hygiene at all levels.
  • Ineffective or insufficient education.
  • A perception that hand hygiene is not needed if gloves are worn.
  • Distractions and forgetfulness on the part of healthcare workers.

Types of Hand Hygiene

Spruce says there are four general types of hand hygiene that should be performed in the perioperative environment: washing hands that are visibly soiled, hand hygiene using alcohol-based products, surgical hand scrubs, and surgical hand scrubs using an alcohol-based surgical hand rub product.

“There are specific techniques for each of these types of hand hygiene,” she says.

“Using these four techniques is the most effective way to prevent and control infections among patients and healthcare workers,” says Spruce. “Hand hygiene is inexpensive and achieves a benefit for both populations, reducing the transmission of microorganisms and decreasing the incidence of HAIs.”

Evidence supports the fact that a failure to wash hands appropriately is the leading cause of the spread of multidrug-resistant organisms among patients, Spruce adds.

“Surgical hand antisepsis takes hand hygiene a step beyond hand washing by eliminating transient flora from the hands and reducing resident skin flora,” she says. “Transient flora are colonized on the superficial layers of the skin and are easily removed with washing, but resident skin flora are not only present on the superficial layers of skin, but also in the deeper layers. Therefore, they are not as easy to remove.”

Spruce notes that the AORN “recommended practices for hand hygiene” recommends that hand hygiene should be performed at specific times, including:

  • On arrival at the facility.
  • Before and after every patient contact.
  • Before putting on gloves.
  • After removing gloves.
  • After removing personal protective equipment.
  • After possible contact with blood or other potentially infectious materials.
  • Before and after eating.
  • Before and after using the restroom.
  • Before leaving the facility.
  • When hands are visibly soiled.

“Perioperative personnel should review and be mindful of these recommended practices and keep reminders of them visible in a prominent place to help ensure that good practices become habit,” says Spruce.

OR Today Magazine | January | Cover Story | Quote Lisa Spruce

Effective Hygiene is in Our Hands

The Joint Commission Center for Transforming Healthcare has created the acronym HANDS to help healthcare workers remember the five keys to effective hand hygiene:

Habit: Always wash in and wash out when entering or exiting a patient care area and after patient care.

Active feedback: Coach and intervene to remind all OR staff about the importance of washing their hands, and clearly state the hospital’s expectations with regard to hand hygiene.

No one excused: Hold everyone accountable and responsible for proper hand hygiene, with no exceptions, and apply progressive discipline from the top.

Data driven: Utilize a sound measurement system to determine your hospital’s real hand hygiene compliance rates, and measure the specific, high-impact causes of hand hygiene failure.

Systems: Make hand hygiene easy for healthcare workers by examining their workflow and providing convenient access to hand hygiene equipment and hand sanitizer dispensers.

Technology solutions can also help hospitals improve hand hygiene compliance. One example is a group monitoring system (GMS) that electronically monitors, tracks and reports hand hygiene compliance rates in real time.

“These systems are a significant advancement over current methods used to determine compliance rates like routine observation, manual product utilization calculations and self-reporting,” says Heather McLarney, the vice president of marketing for DebMed, which offers the DebMed GMS.

“Group monitoring systems provide healthcare workers with immediate access to hand hygiene compliance data 24/7, and hospitals with a cost-effective way to measure, report and act to improve compliance rates,” she says.

McLarney adds that hospitals should look for a system that reports on the World Health Organization’s Five Moments for Hand Hygiene, the recommended standard, versus just the two moments of “in and out” of the OR.

A No. 1 Priority

Given the significant impact that hand hygiene has not only on patient health and safety but also on the healthcare economy, healthcare facilities “need to make hand hygiene a number one priority in the prevention of HAIs,” says Spruce. “The goals are to refresh perioperative personnel’s knowledge of hand hygiene and instill a new sense of urgency to protect patients and healthcare workers from the potential of developing an HAI and spreading it to others.”