Hand Hygiene Compliance Poor and Self-Assessment Unreliable

Daniel M. Keller, PhD

October 26, 2011

October 26, 2011 (Boston, Massachusetts) — According to George Bernard Shaw, "the greatest problem in communication is the illusion that it has been accomplished." It appears that this also applies to the hand hygiene of healthcare workers.

The results of a study of hand hygiene were presented here at the Infectious Diseases Society of America (IDSA) 49th Annual Meeting by researchers from the University of Texas Medical Branch (UTMB) in Galveston.

When Ahmad Ashfaq, MD, infectious disease fellow, and Glen Mayall, MD, implemented a hand hygiene compliance measurement system using direct observation, they found that an established self-assessment method of measuring hand hygiene compliance greatly overestimated compliance and was not reliable. The direct observation system depended on a designated person on each unit openly observing other members of the unit and reporting compliance.

Poor Hand Hygiene Overall; Worse With Doctors

Hand hygiene compliance is an effective aspect of infection control in healthcare settings. To measure compliance by direct observation, the researchers trained students from UTMB professional schools to make unannounced and "secret" direct observations of the hand hygiene practices of healthcare workers in 22 inpatient units.

Dr. Ashfaq told Medscape Medical News that direct observation is considered the gold standard for assessing compliance.

The data gathered were compared with hand hygiene self-assessment data collected by the Department of Healthcare Epidemiology, which had a mean overall self-assessment compliance rate of 94% (range, 80% to 100%).

In sharp contrast, of 9124 monitored hand hygiene opportunities from January 24 to July 31, 2011, the investigators observed 3208 opportunities in which hand hygiene was accomplished, resulting in a probability of hand hygiene performance of 0.352 (95% confidence interval, 0.342 to 0.361). "So 35% of healthcare workers were compliant with the hand hygiene practices," Dr. Ashfaq reported. That includes hand hygiene with either alcohol gel or soap and water.

The burn unit had the highest compliance (58%), and the medical/surgical unit had the lowest (20%). Nurses performed statistically better than the overall rate, with 38.8% compliance (P < .001); physicians were significantly below the mean, at 27% (P < .001). Women were 23% more likely to meet a hand hygiene opportunity than were men (< .001). There was better compliance after patient contact than before (P < .001).

The self-assessment score was near the direct observation value in only 1 of the 22 inpatient units (approximately 55% vs 50% compliance). All the rest had self-assessment ratings that were at least double the values found by direct observation. For 1 unit, it was 5 times higher.

Dr. Ashfaq said that more than 99,000 deaths each year are attributable to healthcare-associated infections, costing more than $5 to $6 billion for treatment. Several studies have shown that a major proportion of these infections are preventable, "and hand hygiene is the key," he said. "The message is that if we can do [hand hygiene], we can not only save lives, we can save a lot of money as well."

To improve hand hygiene, one must be able to gauge it effectively and work to improve it. We "proved that self-assessment is not a reliable way to assess hand hygiene compliance," Dr. Ashfaq concluded.

David Gilbert, MD, professor of medicine at the Oregon Health Science University in Portland, and past president of the IDSA, who was not involved in the study, listed 5 ways to encourage hand hygiene compliance when he spoke with Medscape Medical News.

First, he said, "I think the alcohol rubs have been a great advance.... We're much better [at hand hygiene] than we were 5 years ago (or whenever alcohol rubs became generally available), because [the problem of] washing your hands is partly the lack of convenience. There aren't enough sinks to have one in every room or right outside every room, [but] the alcohol rubs of ubiquitous; we don't have excuses."

Second, he said, patients and caregivers are encouraged to insist on hygiene. "I think having the people at all levels remind the caregivers to wash their hands [is a good thing].... I know one hospital taught patients to ask the doctors and nurses when they came into the room: 'Have you washed your hands?' "

Third, Dr. Gilbert said, there is a major educational effort to get caregivers in the habit of rubbing their hands with alcohol gel while greeting patients.

The fourth technique to encourage hygiene compliance is exposure. "Publication of the doctors not complying is another incentive. None of us want to be embarrassed by the fact that we're caught not washing our hands," he said. "I don't think that we'll ever get to 100%, because in the heat of battle sometimes you don't have time to worry about such things, but we can certainly do better than we're doing."

Finally, besides using "secret shoppers" to assess compliance by observing staff, Dr. Gilbert said his hospital is testing an electronic monitor. "There's actually a device that you can put on the wall in every patient's room, or wherever else in the hospital you want doctors to wash their hands. You wear a little receiver on your lapel, which records whether it senses the alcohol [vapor]. [The receiver] sends a message to the monitor" identifying the specific user and whether he or she used the alcohol rub, he explained. "Then you get a score card."

Dr. Ashfaq intends to incorporate some of these techniques in a follow-up study. The investigators plan to have healthcare workers select a hand hygiene product, to improve the placement of dispensers for that product, to measure hand hygiene practices and provide feedback to healthcare workers about their performance, and to implement an education and awareness campaign. Then they will assess compliance again.

The study received no commercial funding. Dr. Ashfaq and Dr. Gilbert have disclosed no relevant financial relationships.

Infectious Diseases Society of America (IDSA) 49th Annual Meeting: Abstract 508. Presented October 21, 2011.

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