Yes We Can, Vol. 2: Sustaining a Gain
I’ve been hospital epidemiologist at the Iowa City VA Medical Center since 2000 (a position I will soon be leaving, to free up much-needed time to direct our ID fellowship training program). For the past decade we’ve been doing the same things everyone else has to improve hand hygiene, but we remained stuck at about 60-65% adherence. The past few months, though, we’ve seen a clear favorable trend. In March we had over 80% hospital-wide adherence, with every unit above 80% except for one (which was at 76%). We’ve set our goal at 90%, and we’ll see if we can reach it, and then (more challenging) sustain it.
I’ve been thinking a lot about whether sustained excellence in hand hygiene performance is achievable, and I wonder if, over time, we’ll see views on this change just as they did about the “preventable fraction” of healthcare-associated infections. I’ve never been a big fan of “get to zero” language (for several reasons--the pathophysiology of some infections is not amenable to available preventive approaches, and our diagnostic tests and definitions are not perfect). But I’ve never understood how someone could push a “zero” message but remain nihilistic about hand hygiene adherence. If 60-70% really is the best we can do in hand hygiene adherence, we’ll never eliminate healthcare associated infections! So I think elimination paradigms must assume that sustained excellence in hand hygiene can be achieved.
The other thing I’ve noted is that our hand hygiene improvement coincides with improvement in several other areas—for example, over 85% of our staff accepted flu vaccination this season, we’ve gone months without a VAP or CLABSI, etc. If I thought I knew what led to this “tipping point”, I’d tell you. The major facilitator, if I had to guess, has been increasing administrative engagement and resource allocation (examples include the provision of a robust reward system for units achieving high flu vaccination rates, and hiring of a dedicated hand hygiene observer).
I’ve been thinking a lot about whether sustained excellence in hand hygiene performance is achievable, and I wonder if, over time, we’ll see views on this change just as they did about the “preventable fraction” of healthcare-associated infections. I’ve never been a big fan of “get to zero” language (for several reasons--the pathophysiology of some infections is not amenable to available preventive approaches, and our diagnostic tests and definitions are not perfect). But I’ve never understood how someone could push a “zero” message but remain nihilistic about hand hygiene adherence. If 60-70% really is the best we can do in hand hygiene adherence, we’ll never eliminate healthcare associated infections! So I think elimination paradigms must assume that sustained excellence in hand hygiene can be achieved.
The other thing I’ve noted is that our hand hygiene improvement coincides with improvement in several other areas—for example, over 85% of our staff accepted flu vaccination this season, we’ve gone months without a VAP or CLABSI, etc. If I thought I knew what led to this “tipping point”, I’d tell you. The major facilitator, if I had to guess, has been increasing administrative engagement and resource allocation (examples include the provision of a robust reward system for units achieving high flu vaccination rates, and hiring of a dedicated hand hygiene observer).
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