Improving Hand Hygiene Compliance
By Adi V. Gundlapalli, MD; Barbara R. Mooney, RN, BSN, CIC; Louise Eutropious, RN, BSN, CIC; William Stockdale, MBA; Arthur Turlak, MS; Clint C. Bodily, BIS
Low rates of hand-hygiene compliance among healthcare workers (HCWs) are a major healthcare problem. A performance improvement intervention project was initiated in October, 2000 to assess the impact of a multi-dimensional strategy to improve hand hygiene compliance at a tertiary-care hospital. The intervention project was completed Oct. 15, 2001, and thus far has demonstrated remarkable improvements in compliance.
The key to the improvement we have seen has been the introduction of a multi-dimensional approach that recognizes the needs of both HCWs and their patients. Thatcher Pharmaceutical Co. of Salt Lake City provided free quantities of GelSan, an ethyl alcohol-based hand sanitizer gel with moisturizers for the duration of the project. Thatcher supplied the gel in dispensers that were placed at the entrance to each room in the intervention units.
After enlisting the support from nurse managers and unit medical directors, meetings were held with HCWs to explain the project and provide the latest information on the efficacy of alcohol-based gels. Workers were instructed that the alcohol gel could be used for hand hygiene whenever hands were not visibly soiled with body substances. Since gels do not mechanically clean the hands, a traditional soap-and-water wash was required if the hands were visibly soiled. Signs and posters were posted throughout the units to help remind HCWs of the need to perform hand hygiene.
Based on the experience of infection control personnel and documented evidence from several years of microbial studies, extra isolation precautions were removed from the intervention units for some organisms, specifically, the requirement to isolate patients having vancomycin-resistant Enterococci (VRE). Hand hygiene, when performed consistently and well, has been shown to be very effective in decreasing the spread of organisms between patients. Body substance precautions require the standard use of barriers, such as gloves, masks/goggles, and gowns, based on the intervention with the patient, not based on the diagnosis. These two interventions encompass the unknown or unrecognized carrier in addition to the recognized carrier of VRE, making additional precautions redundant. This saves time and money for the facility, and the patient benefits by receiving more care by HCWs.
Regular meetings took place with the HCWs on the project intervention units. Infection control nurses met regularly with unit nurse managers, while the hospital's epidemiology physicians met regularly with medical directors, residents, and house staff. The HCWs were provided with current compliance and transmission information and encouraged to guide the future of the project.
The project compared compliance between four patient-care units. Initially, two adult intensive care areas were involved as the intervention units for the elements mentioned above. Two other areas, where none of the interventions was initiated, had compliance measured in the same manner as the case units. Compliance was measured by trained observers who visited each unit on a random basis. For about an hour on each unit, the observers recorded the activities of the HCWs in terms of whether or not the worker performed hand hygiene (a soap-and-water wash or waterless wash with GelSan) when approaching or leaving a patient. To date, more than 12,000 observations have been made.
After 6 months of successful outcomes from the initial period, the third and fourth units were fully incorporated into the project and received the same interventions. Thatcher Pharmaceutical provided additional dispensers with GelSan so that they could be conveniently located and available to all HCWs when they enter or leave a patient's area. After being incorporated into the project, the third and fourth units were compared to the other test units.
Over a 9-month period, an active, multi-dimensional campaign resulted in a significant increase in hand hygiene compliance at our institution. The initial units, ICU #1 and ICU #2, went from a compliance rate of 27.5% to 49.3%. The second set of units, ICU #3 and Unit #4, went from 24.6% to 39.4%.
One key to this improvement was the speedy reaction by Thatcher Pharmaceutical to include our feedback into the design of the product, to include a professional infection control perspective, and to improve acceptance of the gel with various medical staff departments. The gel began to catch on with our staff, and other units outside of the study adopted GelSan.
Instituting a change in human behaviors must often take place in incremental steps. For years, the hospital emphasized hand hygiene using soap and water. We are now urging the use of GelSan whenever hands are not visibly soiled; soap-and-water hand hygiene must still be used if hands are visibly soiled. We estimated that more than 80% of the hand-hygiene opportunities were when HCWs' hands were not visibly soiled.
We anticipated some resistance to change. Experience with alcohol products in the past left HCWs concerned about their hands drying out and cracking or chapping. Regardless of instruction about how the use of soap and water can actually damage the skin over time--leaving places which harbor pathogens--HCWs have been taught and have relied on this method for a lifetime of patient care and self-care. However, it was evident by our observations that using an alcohol-based product specifically designed with emollients that preserve the skin quickly gained acceptance. During the study, we have measured the rate of soap and water hand hygiene vs. waterless hand sanitizing. Figure 2 demonstrates the acceptance of the new method.
Over a 9-month period, our multi-dimensional campaign has resulted in a significant increase in hand hygiene compliance at our institution. The use of a gel designed to preserve skin integrity was a key factor that helped to increase our compliance. We also found that educating staff about the importance of hand hygiene and placing gel dispensers in high-traffic areas helped increase the frequency of both soap-and-water and alcohol gel washing in our facility. Future projects include evaluation of the long-term effects of the campaign, hospital-wide implementation of the campaign and formal survey of HCWs' perceptions toward hand hygiene and its importance.
The above study was completed by the University of Utah.