Suspension of Privileges Improves Physician Adherence to Hand Hygiene

Bob Roehr

October 09, 2007

October 9, 2007 (San Diego) -- Education and leadership are important components in increasing physician compliance with hand hygiene, but the suspension of privileges really changed behavior at one hospital, according to a study presented here at the Infectious Diseases Society of America 45th Annual Meeting.

Cedars-Sinai Medical Center in Los Angeles, California, identified hand hygiene compliance as an institutional priority in September 2004. It set a goal of achieving 90% compliance by March 2005 and sustaining that for 3 months, said presenter Rekha Murthy, MD. Compliance at baseline was about 65%, with nurses leading the way at nearly 70%, whereas physicians and other healthcare workers hovered just under 50%. This pattern reflected what has been seen in the literature.

The hospital implemented a multifaceted hospital-wide campaign that included education of all healthcare workers and patients; physical changes to make hand hygiene dispensers readily available at the entry to each room, as well as individual pocket dispensers; and measurement and feedback. Observation teams were trained to evaluate and report compliance.

By January the campaign had increased compliance to 75% systemwide, rising to 86% in March. Nurses again led the way: They were the only group to surpass the goal of 90% compliance, and they maintained it for the 3-month study period. Dr. Murthy's data showed that the physicians were the most recalcitrant; there was wavering improvement from baseline, but compliance never surpassed 69% for a single month of the study period.

That outcome led to a redoubled effort by hospital administrators. At a regular lunch meeting of staff physicians, 20 of them were asked to submit to unannounced cultures of their hands. The results of these cultures were shared with individual members, photographed, and displayed at a subsequent meeting of the committee, Dr. Murthy said.

"The experience underscored the personal nature of hand hygiene and was perceived by members of the group as a profound lesson," she said. However, it had little effect on overall compliance among physicians.

Cedars-Sinai then turned to a peer-to-peer discussion approach. Putting a bit of a lighthearted face on the campaign, the administration formed "Hand Hygiene Posses" of department chairs, medical staff officers, and medical executive committee members, who rewarded good behavior with Starbucks gift cards and reprimanded those they caught violating the policy.

Finally, one physician had his privileges suspended after repeated violations of isolation precautions, including hand hygiene. Dr. Murthy said the news quickly spread among the more than 2000 physicians who practice at the facility, and their compliance immediately improved, although it still fell a slightly short of the 90% goal. "The suspension was lifted after peer review, counseling, and education on infection control.

"Physician leader involvement was critical for success," she noted, but "sustained hand hygiene compliance requires a large-scale and ongoing organizational effort."

One benefit is that "over the 2-year course of the hand hygiene program, the cultured [methicillin-resistant Staphylococcus aureus; MRSA] bacteremia rate has steadily declined by over 50%," Dr. Murthy said. This was during a period when Los Angeles was undergoing an extensive series of outbreaks of community-acquired MRSA.

Why did the nursing staff initially attain and maintain the high goals set for hand hygiene? Dr. Murthy believes "part of it is that they are unit based...and they are tracked by their nursing performance. So, at the nurse manager level there was significant incentive to comply," she told Medscape Infectious Diseases.

Session cochair David Weber, MD, MPH, medical director of hospital epidemiology at the University of North Carolina, Chapel Hill, was impressed with the study. He said, "The average compliance is around 40%, and I'm not aware of any study that has been published that has shown a consistent improvement above 80%. So it is good, but it would be nice to see longer-term data."

He was not surprised "that nurses do a better job than physicians" in terms of hand hygiene. He suspects it might be because nurses have more and longer direct contact with the patients who become infected, whereas a physician, particularly a consulting physician, "just steps in and steps out.

"I haven't seen any data, but I suspect there tend to be more sanctions against nurses than physicians for not doing what they should do," Dr. Weber said. He believes the incident in which a physician's privileges were suspended helped to increase compliance among physicians. He said, "If there are real consequences, compliance will be higher."

The speakers disclosed no relevant financial relationships.

Infectious Diseases Society of America 45th Annual Meeting: Abstract 566. Presented October 5, 2007.

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