Fake News in Your Hospital: Hand Hygiene Compliance

Fake news and how it influences policy and politics has been grabbing headlines lately. I'm sure many who read this blog are rightly concerned about this development. If we can't even agree on the truth, how can we set about making policy and solving problems?  What struck me about the fake news discussions is that we have an example of fake news in our hospitals - reported hand hygiene compliance!

A few weeks ago, I wrote that hand compliance in your hospital is likely between 34% and 57%, since a review of trials published since 2009 reported those levels before and after interventions were implemented. Apart from that study, how can I know your true compliance rates when you're reporting hand hygiene compliance rates over 90%?  I have several reasons.

First, harken back to this 2010 interview of Mark Chassin, then and current President and CEO of The Joint Commission. In the interview, he shared the initial results of their "proven effective solutions for improving hand hygiene compliance in hospitals", which were developed in 8 center hospitals and further evaluated in 29 additional hospitals.  At the beginning of this project, hand hygiene compliance was 48%. Look at what Dr. Chassin said about the baseline rate - "It’s interesting that a number of the hospitals were misled by faulty data to believe that they were doing as well as, say, 85%, at baseline rather than 48%."

Second, even after their huge hand hygiene initiative, they were only able to get compliance up to 82%. Interesting, so even The JC acknowledges that you can't get to 90% compliance. Yes, but that was 2010, what about 2017?

Third, The Joint Commission's National Patient Safety Goal 07.01.01 for 2017 doesn't require hand hygiene compliance over a specific threshold (see Figure below). Hospitals only have to set goals for improving compliance and then improve compliance based on those goals.  So why do hospitals continue to set unreachable goals for hand hygiene compliance (say over 90%)? Are there downsides with setting fake goals - do they hurt our credibility, do they result in a feeling of learned helplessness among clinical and infection prevention staff and do they harm our patients?

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Side note: One of the things that struck me when rereading the Chassin interview is the dissonance between the primary barrier to hand hygiene compliance that The Joint Commission identified and their planned "next steps" to get compliance above 82%. I pasted the quotes below. Do you think their interventions addressed the identified barrier?  Me neither.

Primary Barrier: "So, for example, for one of the causes (“hands full”), which was a surprise for many of the participants, caregivers approach a patient’s room with their hands full—for example, a nurse is carrying materials to do a dressing change—and there’s no place to put the materials down. The hand-gel dispenser is right there, on the wall, but there’s no place to put the materials down, so what do you do?"

Joint Commission Solution: "We’re looking to industry to address one of the more difficult parts of sustaining and getting past 80%, namely, replacing this very labor-intensive measurement system with devices, software solutions, and applications that are relatively inexpensive but will provide real-time feedback on performance."

Image Source: AIM

Even with the Hawthorne Effect, Hand Hygiene Compliance Still Hideous

One way to deal with low hand hygiene compliance

A recurring theme has emerged in hand hygiene science - when you really look, compliance is very very low. A study 5 years ago reported that compliance was below 10% when hidden video monitoring was utilized. Our group has quantified the impact of the Hawthorne Effect, improved behavior when subjects know they're being observed, on hand hygiene compliance. In a multicenter study, we found that both measured exit and entry compliance increased the longer direct observers remained on the unit.

There is a report of a new APIC abstract in ABC-News that further quantifies that impact of the Hawthorne Effect and highlights the lack of investment in hand hygiene programs. Investigators from Santa Clara, California compared compliance measured by well-recognized Infection Prevention nurses, to observations collected by unknown high-school and college-aged volunteers who were trained to use the same surveillance methods. Here are their findings:

So, what do I make of these findings? First, even 57% is too low. Second, hospitals and healthcare systems continue to throw hand hygiene programs under the rug. We are much happier to report compliance rates of 100% collected by nurse managers on the floor (or compliance of 57% by recognized IPs) and ignore the problem than spend time and money detecting compliance rates of 22%, which would then require additional investments in proven hand hygiene interventions.

Any administrator, who thinks compliance in their hospital is higher than 70% or 90%, won't invest in hand hygiene programs. Since hospitals are happier to report compliance of 90% to the Joint Commission, we also won't invest in technological and socio-adaptive interventions that will finally improve the safety of our hospitals. We must work to create a safety culture where it is better to report hand hygiene compliance of 20% than falsely high compliance rates of 90%.

image source: montonara.com

Why can't we easily clean our stethoscopes?

I just finished two weeks on the inpatient internal medicine service. When we round on the service every morning, I insist on 100% hand hygiene and 100% stethoscope hygiene but one of these targets is far easier to achieve than the other. As Mike mentioned last year, almost 50% of stethoscopes are contaminated with pathogens including S. aureus and MRSA. Despite this level of contamination, hospitals have done almost nothing to make cleaning them quick and easy. Like many (? all) hospitals, we have hand rub dispensers every few feet but nothing easily available to clean our stethoscopes. I usually end up "bothering" nurses to give us a few alcohol prep pads, but this uses up their daily supply and generally seems like an unnecessary barrier. Why can't we have wipes next to the hand rub dispensers outside of every room? That way we can actually achieve 100% stethoscope hygiene. If we don't develop good systems, we can't expect good results. How do you guys practice stethoscope hygiene at your hospital?

Hand hygiene compliance at your hospital is not 90% and it's probably not even 80%

A few weeks ago, we got a review back on a manuscript (fortunately accepted with minor revision) but one of the reviewer's comments was an example of truthiness invading infection prevention.  The comment was one we hear often and since you can't typically communicate with a blinded-reviewer, I thought I'd mention the comment and what my response would be here.

Reviewer: "...only 63% of HCWs performed hand hygiene on exiting the room...in the year 2012, compliance rates of 50-63% is just plain depressing..." This comment and the other comments by the same reviewer seem to suggest that the four hospitals in our study were outside the norm and that we should clearly have hand hygiene compliance above 90%.

My (theoretical) reply: Hand hygiene compliance rates are not as high as reported.  Many things can explain this from the Hawthorne effect to only collecting data during 9-5 business hours. Fortunately, we have data from The Joint Commission Center for Transforming Healthcare.  In 2009 they began a hand-hygiene project.  Dr. Mark Chassin, President of The Joint Commission, described the project in a 2010 interview:

"We are collecting data from all Center hospitals. We are continuing to do so even for the eight hospitals that participated in the hand hygiene project, past its formal closure. In April 2009, at the beginning of the project, performance was collectively at 48% and has now stabilized at around 82%. It’s interesting that a number of the hospitals were misled by faulty data to believe that they were doing as well as, say, 85%, at baseline rather than 48%. So getting reliable measures was understandably a big issue at the start of the project."

When we do hand hygiene studies we use a uniform extraction sheet and collect data from all hours. We also collect 1000's of hours of data. From our experience, it is likely that hand hygiene in most hospitals is closer to the 50% reported in the 2009 Joint Commission study and not near the claimed 90% that everyone likes to see.

Final note:  If we think compliance is 90% we will do nothing, but if we accept the fact that it is 50% or 63%, we can address that with further interventions or initiatives. Acknowledging this is a necessary first step in making our hospitals safer.

Source: An Interview with Mark Chassin, The Joint Commission on Quality and Patient Safety, October 2010.

Feedback loops! Feedback loops! Feedback loo...

Feedback loop photo from wired.com

Several years ago (yikes!) Dan blogged about 'closing the loop' by providing real time reminders to doctors that their hands are contaminated.  To paraphrase his money quote: "So I think several varieties of feedback will do..It is essential, though, that such feedback be provided as close to the point of care as possible."

There is a very interesting piece in last months Wired that discusses the success of just the type of feedback loops that Dan suggested.  The initial example they give of a successful feedback loop is those real-time dynamic speed displays, or driver feedback signs, that have a speed limit posting coupled with a huge sign announcing “Your Speed.” In this example, speeds fell 14% and were below the speed limit!  I guess you can change behavior.

Could we incorporate such feedback, "as close to the point of care as possible" as Dan suggested, and improve hand hygiene compliance by 14%? Anyway, a very interesting article and they even included a podcast/mp3 that is a good listen.

Source: Thomas Goetz "Harnessing the Power of Feedback Loops" Wired June 2011

Another benefit of hand hygiene!

We are always looking for ways to improve hand hygiene. Researcher Spike Lee at the University of Michigan has just published a creative study in the journal Science. In the study, subjects were asked to make a difficult decision. The subjects who washed their hands after making the decision, had lower cognitive dissonance; they were more at ease with their tough decisions. You can hear more about the study on this weeks Science Friday on NPR (here). Now if we could get our clinicians to round in the room (as some used to) and make decisions in the room, we could really increase our exit compliance. As it is, we could at least improve our entry compliance if we made the study results more available. Feel good about yourself: wash your hands!

You're Fired!

Those are the two words that hospital epidemiologists everywhere wish they could say to non-compliant healthcare workers. At least it's one of my dreams. According to a story in the Philadelphia Inquirer, if you're the lucky infection preventionist at Abingdon Memorial Hospital in Pennsylvania you can actually say that to clinicians that don't wash their hands on room entry and exit. After several years of trying to improve compliance with education and constantly retelling a tragic story of a patient's death from MRSA (the mother of one of the hospital's primary care physicians), they were able to improve hand hygiene compliance from 31% to a plateau of around 80%. With this improvement they report reductions in CLABSI, VAP and SSI but not UTIs.

However, they weren't satisfied. Their new plan is to give index cards to compliant staff that make them eligible for a raffle (carrot). What do non-compliant individuals get? The same cards but with a message that they have one strike against them (stick). If they get three strikes, they will receive a letter that their reappointment is conditional and they might lose their job. It will be interesting to see if compliance improves and if anyone is fired. I suspect the observers may be hesitant to give out that third strike, but I hope not. I also hope my title doesn't infringe a Donald Trump trademark.

Compliance with contact precautions: Not so much

Elaine Larson's group has a new study in the American Journal of Infection Control that examines compliance with contact precautions at 3 hospitals in New York City. She found that 15% of patients who had indications for contact precautions were actually not isolated. For patients who were isolated, hand hygiene by healthcare workers on room entry was very low at 22% and on room exit at 59%. Compliance with gowns was 71% and with gloves 72%.

With the compliance levels demonstrated here it seems unlikely that these hospitals could be successfully preventing infections. I am increasingly convinced that effective infection prevention hinges on high levels of compliance with very basic practices. It's not rocket science.