Even COVID Can't Convince Clinicians to Maintain Hand Hygiene

Diana Swift

April 28, 2021

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Hand hygiene is an essential part of nosocomial infection control, yet compliance remains low, historically averaging 50% in US hospitals.

A new study has found that one hospital achieved daily compliance rates of more than 90% during the first part of the pandemic last spring, reaching a peak of 100%, although it was unable to sustain that level. Staff soon went from being compliant to being complacent, and rates returned to a prepandemic baseline within a few months, despite ongoing COVID-19 outbreaks around the country.

The results of the study, by Sonya Makhni, MD, MBA, of the University of Chicago Medical Center (UCMC), Chicago, Illinois, and colleagues, were published online April 26 in JAMA Internal Medicine.

"As hospitals set hand hygiene goals, this study suggests high compliance is possible, even with automated monitoring, yet difficult to sustain," the investigators write. This drop in compliance should be a "clarion call to hospitals" currently experiencing COVID-19 surges, they continue.

"We've been routinely monitoring hand hygiene at our center for 5 years, and we noticed that compliance went up in early March, and we wanted to know why it was increasing," senior author Rachel Marrs, DNP, RN, CIC, director of UCMC's infection control program, told Medscape Medical News. "We saw that staff were washing and sanitizing more often, but they were also batching more tasks to do them all at once so there was less time going in and out of patient rooms."

Data for the current study came from UCMC's automated hand hygiene monitoring system, which was installed in 2015. The system uses an infrared sensor to anonymously record all uses of soap and sanitizer dispensers (numerator) as well as entries into and exits out of inpatient rooms (denominator) to estimate hand hygiene compliance (numerator/denominator) for each inpatient unit. To inform staff, the system graphically displays trends on centrally located unit monitors and communicates data weekly.

Makhni and colleagues analyzed compliance in UCMC's adult hospital by day, week, and month from September 2019, before the pandemic, through August 2020. They also examined compliance on two hospital floors that had been temporarily converted for the exclusive care of COVID-19 patients (cohort units). The investigators hypothesized that these units would reflect maximum adherence.

The researchers factored in the number of sanitizing opportunities (room entries and exits) as well as COVID-positive inpatient admissions by month. Their study included 13 validated inpatient units and six intensive care units, comprising 436 beds overall.

During the study period, 1159 inpatients with COVID-19 were admitted. The monthly peak occurred in April 2020. In the months before the declaration of the pandemic, monthly hand hygiene compliance across all units was similar to the September 2019 baseline, at 54.5%. During the pandemic, compliance rose, reaching a daily peak across all units of 92.8% on March 29, 2020, and peaking at 100% on March 28, 2020, in the COVID cohort units.

Similarly, the highest weekly rate occurred during the week of March 29, 2020, at 88.4% across all units and 98.4% in COVID cohort units. A monthly peak of 75.5% across all units and 84.4% on cohort units occurred in April.

The compliance surge appeared to have been driven by fear and increased awareness of hand hygiene at the start of the pandemic, the authors say. Hand hygiene opportunities declined with the drop in the number of room entries and exits, as well as in conjunction with clinicians' conducting rounds remotely and nurses' batching of tasks while in patients' rooms.

After the spring peaks, compliance declined across all units to a daily nadir of 51.5% on August 15, 2020, a weekly nadir of 55.1% in the same week, and a monthly nadir of 56% in August.

Reasons given for neglecting hand hygiene mainly related to human factors. They included clinicians' having their hands full and emergent treatment demands. "Sometimes staff said they were preparing to admit a patient and were carrying items that they didn't want to set down," Marrs said. "Sometimes they were treating really sick, high-acuity patients, and they honestly just forgot."

There was no drop in compliance over the course of shifts as staff became more fatigued, but adherence did drop significantly with disruptive events such as code alerts or attending to decompensating patients. "But it then tended to go back up," Marrs said.

In previous studies, hospital personnel have attributed nonadherence to factors such as skin irritation, inaccessible supplies, interference with worker-patient interaction, the needs of patients taking priority, wearing gloves, forgetfulness, ignorance of guidelines, insufficient time, high workload and understaffing, as well as lack of scientific information demonstrating the effect of improved hand hygiene on hospital infection rates.

Offering his perspective on the findings, Jerome A. Leis, MD, medical director of infection prevention and control at Sunnybrook Health Sciences Center, Toronto, Canada, said, "Not surprisingly, the COVID-19 waves only led to temporary improvements in hand hygiene practices. In order to make more durable practice changes, this requires years and not months."

During COVID-19 pandemic waves, his institution similarly recorded spikes in improvements. "We know that context can heavily influence hand hygiene behavior by altering risk perception and reinforcing best practices," he said. "It is normal to see ups and downs in performance, but it is the overall trajectory year over year that is most important."

Leis, who has studied the association of hand hygiene and outbreaks, said electronic monitoring combined with staff huddles on inpatient units has led to a steady increase in compliance. Electronic monitoring has proven to be superior to direct observation through random audits, because behavioral changes occur when observers are present. "This is the reason we moved to electronic hand hygiene monitoring, which measures continuously and is far more accurate," he said.

As the pandemic continues, Marrs's group at UCMC is working on strategies to keep adherence high. "We have 15-minute virtual huddles across different units. We get nurses in pediatric or COVID or intensive care units together and go over the compliance rates for the last week and address obstacles and barriers. We have power-hours in individual units where we try to get compliance up to 100%," she said. These focus exercises have proven helpful.

For the moment, UCMC has met its overall goal of 60% compliance, Marrs said. "We're creeping up slowly, but some units are still back at baseline, around 50%, while others are up over 80%."

The study was supported in part by the Center for Healthcare Delivery Science and Innovation at University of Chicago Medicine. One coauthor has received travel support from GOJO Industries to speak about hand hygiene. The other authors and Leis have disclosed no relevant financial relationships.

JAMA Intern Med. Published online April 26, 2021. Full text

Diana Swift is a medical journalist based in Toronto. She can be reached at dianaswift@rogers.com.

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