Patient Empowerment as a Hand Hygiene Strategy

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We asked members of industry to describe the importance of patient involvement in hand hygiene and suggest some best practices for implementation into an existing hospital-based hand hygiene program.

When considering patient involvement in a hospital hand hygiene program, an area that needs consideration is the patient's hand hygiene. Although this aspect of healthcare hand hygiene has been studied minimally, there is cause for concern and clearly a need for more study in this area. In a recent study which cultured patients' hands after being hospitalized for at least 48 hours on medical-surgical units, 39 percent of patient’s hands cultured positive for Clostridium difficile, vancomycin-resistant Enterococcus, methicillin-resistant Staphylococcus aureus, and Acinetobactor.(1) Further studies are planned in this area to clearly define if organisms are present on admission or acquired during the hospitalization.While there is emerging interest in the patient and their environment as potential sources of healthcare-associated infections (HAIs), these studies also highlight the need for healthcare personnel to assist the patient in their hand hygiene. Many patients are unable to open a towelette package, or to reach the alcohol based hand rub on the wall, or walk to the bathroom to use soap and water after using a bedpan or bedside commode and before eating. There is also a call to action for industry innovators to design patient friendly hand hygiene products and dispensers so that the patient can clean his hands, or the healthcare personnel can conveniently assist the patient with their hand hygiene needs.
1. Istenes NA, Hazelett S, Bingham JE, Kirk J, Abell G, Fleming E. Hand hygiene in healthcare: The role of the patient. APIC Annual Education Conference and International Meeting [15-237]. 2011.
-- Jane Kirk MSN RN CIC, clinical manager, GOJO Industries 

Hand hygiene is key to safeguarding the patient care environment.  It is as important for patients and visitors to practice proper hand hygiene as it is for a healthcare professional. Cross contamination from dirty hands to the patient environment can cause the spread of potentially harmful bacteria. Patients and visitors who are aware and educated on proper hand hygiene are able to take an active role in patient safety.  As part of the healthcare facility's  hand hygiene program, hand hygiene products should be made very accessible to patients and visitors and steps should be in place to create an environment in which patients feel comfortable asking and reminding their caregivers to sanitize their hands. A facility's hand hygiene marketing campaign should include intervention materials such as signage near sinks and hand antiseptic dispensers reminding everyone of the proper hand washing protocols and the importance of hand sanitizing.  In addition, facilities can provide patient focused educational materials on hand hygiene and include hand hygiene-specific questions on patient satisfaction surveys.
-- Andrea Albrecht, global hand hygiene marketing manager, 3M

There have been various studies that express the hesitancy of patients to voice their concerns to healthcare workers concerning hand hygiene.  A recent University of Wisconsin study showed that patients agreed that healthcare workers should be reminded to wash their hands but that they were too embarrassed to ask. Education programs upon entering the hospital that let patients know that it is okay for them to ask everyone to wash before they approach them is a helpful practice. But, there are times when the patient cannot advocate for themselves.  In these instances, electronic hand hygiene monitoring systems that including reminding healthcare workers to wash before patient contact are crucial to stopping infections that are spread from patient to patient via the hands of healthcare workers. Also, it takes away the embarrassment of the patient having to remind their physician or other healthcare worker to wash their hands.
-- Elena Fraser, vice president, HyGreen, Inc.

As we’ve seen from recently published studies, patient involvement is important to a successful hand hygiene program as it relates to staff compliance.  We’ve also seen, however, that patients are reluctant to ask staff about their hand hygiene practices, and staff react negatively to being asked this by patients. We believe the best way to overcome this is to incorporate a hand hygiene improvement system that allows patient interaction in the compliance monitoring process.  The system should include an educational component about a facilities hand hygiene program at admission;  include patient involvement in the compliance monitoring process via a method that does not require them to constantly ask staff or that doesn’t “embarrass” staff with something they wear that beeps or flashes if a staff member is non-compliant; and, lastly,  include a component that not only captures hand hygiene compliance information but also corrects staff, on the spot, if they fail to wash or sanitize according to protocol. 
-- Seth Freedman, president, Intelligent M

The need for visitors and family members to perform hand hygiene while visiting the hospital is established. Family members can unintentionally transmit resistant strains of healthcare and community-associated organisms. Despite the risks, hand hygiene activity among hospital visitors has largely gone unmonitored. 
Proventix is seeing that automated hand hygiene monitoring systems may also prove an effective mechanism for assessing and encouraging visitor hand cleansing. An RFID solution combines caregiver badges with a network of communication units (CUs) that connect to hand hygiene solution dispensers.  The system assesses caregiver hand cleansing compliance as well as counting hand cleansings by visitors, patients and families. While cleansing users receive updated weather, sports, news, and reinforcing “thank you” messages on the CU screen. We monitored 581 dispensers in 10 nursing units for six months. There was a 67.7 percent increase in caregiver hand cleansing and a corresponding 13.95 percent increase in visitor hand cleansing. This gain occurred without efforts to directly improve visitor compliance other than by caregiver example. Our messaging screens provide a prominent, lighted visual cue and point of interest for visitors, drawing attention and encouraging hand cleansing without staff direction. Additionally, increased hygiene activity by hospital staff serves to positively influence visitor behavior.
-- David Sellers, chief clinical officer, Proventix Inc.

In the healthcare setting, everyone is responsible for working together to decrease the risk of infection, from healthcare workers to visitors and patients themselves. DebMed, creator of the world’s first and only electronic hand hygiene compliance monitoring system based on the World Health Organization (WHO)'s Five Moments for Hand Hygiene, has a web-based toolkit that works in conjunction with the monitoring system to help hospital clients improve patient safety by reducing infections through an increased focus on hand hygiene compliance. The toolkit provides training materials designed to help staff facilitate dialogue regarding the hand hygiene compliance data collected from the monitoring system, as well as patient-facing tools such as handouts on proper hand cleaning techniques and posters reminding them to clean their hands, an important part of reducing infections. While most healthcare workers know the importance of proper hand hygiene, they benefit from being reminded regularly. In addition, patients and visitors need to be informed of their responsibility and role in the process of preventing healthcare-associated infections, which is to clean their own hands frequently and remind healthcare workers about hand hygiene compliance. 
-- Paul Alper, vice president of strategy and business development, Deb Worldwide

The most important part of any movement toward increased patient involvement in an existing hospital-based hand hygiene program is education. HandGiene Corp.’s motto is “Education is the Key but Monitoring with Accountability is the Answer.” That is why patients and visitors need to be more fully educated regarding the importance of hand hygiene compliance in much the same way as hospital staff.  Pamphlets explaining the importance of hand hygiene should be distributed as a part of the admissions process. Coupling this literature with appropriate signage in public areas and patient rooms will create a more comprehensive and redundant visual reminder system. Staff will be consistently reminded to properly and more diligently perform hand hygiene and patients will be reminded to observe and comment as necessary. Lowering the rates of HAIs and readmissions will positively impact the overall cost of healthcare universally and to the individual patient. By giving the patients the proper educational materials, and empowering them to speak up, they can potentially help themselves by shortening their stay or maybe eliminating a readmission brought on by an HAI caused by poor hand hygiene. Self-interest will motivate patients to get involved. With a proper education patients can make a difference.
-- Richard Verdiramo, vice president, HandGiene Corp.

The idea of patient involvement in the hand hygiene compliance (HHC) process has been around for decades, yet has been shown over and over to be virtually ineffective. Why? Patients have limited ability to actively, or accurately assess whether or not HHC is being practiced given the myriad of interactions that take place by multiple caregivers, on a 24-hour basis. Additionally, patients do not feel comfortable challenging a healthcare provider with the “Did you sanitize?” question. So while patient risk and anxieties regarding HHC are very real, one must ask why any monitoring or compliance burden should be placed on the patient, or family member shoulders? This is particularly the case when signage and other notifications methods commonly seen throughout hospital facilities are communicating, supporting, suggesting that a standard operating policy is in-effect of “gel-in/gel-out." What’s needed is an automatic, personnel reminder and behavior modification solution, one that utilizes a highly visual green, yellow, or red light to indicate the exact status of hand hygiene compliance with every room entry and exit. Such a solution would eliminate the need for anyone having to ask, guess or worry.
-- Brent D. Nibarger, chief client officer, BioVigil

Human hands are the No. 1 transmitter of healthcare-associated infections (HAIs), and effective hand hygiene is the best way to prevent infections from spreading.(1) In a healthcare setting, practicing hand hygiene is everyone’s responsibility – staff, patients, and visitors. Patient involvement in hand hygiene is critically important because while healthcare workers understand how hand hygiene can impact the spread of infections, it may not be as obvious for patients.  An awareness campaign that encourages healthcare workers and patients to work together for better hand hygiene will help highlight the importance of it for everyone and keep hand washing opportunities top of mind. It is important to reach out to patients in a variety of ways to help them understand their role in their own care. Brochures, table tents, posters and videos can all be used to remind patients that frequent hand hygiene helps reduce the spread of infections. These awareness vehicles can also be used to remind everyone that hand hygiene should be done when entering and leaving patient rooms, before and after touching patients, after touching patient surroundings, before and after eating and after using the bathroom. Working together, patients, visitors and staff can help create a safer, healthier hospital visit.
1. http://www.cdc.gov/hicpac/2007IP/2007ip_part2.html
-- Linda Homan, RN, BSN, CIC, senior manager, clinical and professional service, Ecolab Healthcare 

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