Hand Hygiene Monitoring: Here’s How It’s Done

Linda S. Estep, BS MT (ASCP), CIC: “I’ve done many hand hygiene audits in my day, I still do hand hygiene audits, when I’m in the hospitals now. If they know who you are, they scatter. They know the infection preventionists.”

Get ready for some shop talk, infection preventionists. Linda S. Estep, BS MT (ASCP), CIC, and Tracey Odachowski, MSN, BA, RN, CCRN, NE-BC, both work for Sentara Healthcare, a not-for-profit integrated health care system based in Norfolk, Virginia. With 12 hospitals, 4 medical groups, and more than 30,000 employees, it’s Virginia’s largest health care system. Estep is Sentara’s infection prevention manager. Odachowski is the director of infection prevention and control. They have helped orchestrate a hand hygiene program using both low-tech (secret shoppers) and high-tech (electronic auditing) methods. But what really sets Sentara apart, they say, involves creating a culture they call “all hands on deck” in which every employee monitors hand hygiene and won’t hesitate to gently remind someone who hasn’t followed protocols without having the person who’s been reminded feel scolded. And that means every employee. An environmental services (EVS) worker can flag a surgeon—or even a hospital administrator like Odachowski. “I’ve had an EVS worker correct me,” says Odachowski. “It’s all about the culture you build.” And if the person responds defensively or dismissively? “It’s stopped,” says Odachowski. “It is reported to that person’s leadership, and it’s corrected. And if you cannot abide by the culture where we can correct each other and have safety in correcting each other and not fear that retribution, then you need to find another place to work.”

Infection Control Today®:Can you tell us how you developed your hand hygiene program? Maybe begin with why you developed your hand hygiene program?

Linda S. Estep, BS MT (ASCP), CIC: Well, I think that we develop the hand hygiene program because it really is the single most important measure that health care staff can take to prevent the spread of microbes that cause infections. It’s simple. It’s effective. We’ve added some features that make it simpler, easier to do, faster, and also less likely to be done incorrectly. Hand hygiene with soap and water entails a lot of details, a lot of steps, as opposed to the alcohol-based hand sanitizer that we have almost everywhere across the system, that you just grab as you go in and you apply it as you walk into the patient’s room and you begin doing whatever task you’re doing. Chatting with the patient. Checking monitors or that type of thing. We’ve done a lot to try to make it simpler and more effective over time.

ICT®: Infection preventionists do a lot of monitoring of hand hygiene. How do you combine that with new technology?

Linda Estep: There is new technology out there that we have been looking at recently, and we are with the pandemic and the high focus on not only hand hygiene, but also PPE [personal protective equipment], they were hoping to move into the world of electronic hand hygiene monitoring. There are lots of systems out there. There are lots of companies that create those

systems. And several of the companies that do that and are very good at that are already partners with us. We are definitely looking at the electronic piece. But there’s another really important aspect that I want to bring up that kind of bridges the gap between what you’re referring to as low tech, and more high-tech stuff is the culture here at Sentara. And the pandemic has certainly impacted our culture in a lot of ways. In every single way. Tracey can tell you how much it has impacted us. But regarding hand hygiene and our culture of safety that we have spent a lot of time and effort over the years developing that is even more important because we have to remind one another. All the health care staff is super busy, stressed out, some of them are burned out. And so, the forgetfulness and the … just the lapses that can happen. If you have a culture of safety in place, your co-worker will say, “All hands on deck. Don’t go into that room without washing your hands.” That piece is really important. The peer coaching and the peer checking.

ICT®: You actually just touched on something that I’ve been thinking about for a while. I can put myself into the shoes of a health care provider. In the emergency room. A patient’s dying over there. Every second counts. And you’re going to wash your hands for almost two minutes? But you just answered my question. You said that basically what you do is that person who is washing their hands will say to a coworker: “Can you check on that patient?” Is that the deal?

Tracey Odachowski, MSN, BA, RN, CCRN, NE-BC: Yes. I think that’s perfectly said. Most of my background has been in intensive care. We face that all day, every day. And the EDs as well. And so, I dare you to find a single health care worker that hasn't missed a handwashing opportunity at least once. And I’m sure it’s probably much more than that. By building a culture that you’re safe

to check and peer coach each other, without fear of retribution, or someone getting angry at you. We’ve made it more comfortable to be thankful that someone did that. I myself have done it. You’re in an emergency or flying into the room. And someone just did a quick tap: “All hands on deck.” And that’s the phrase that our system has created to make it our safe phrase. It doesn’t sound horrible to the family or the patient. We just do a quick “all hands on deck” and say, “Oh, thank you.” Do it quick. And there are so many things that you can do while you’re doing your hand sanitizer with your eyes. And you just need to wait those few seconds for your hands. And there’s another set of hands that are already cleaned that can do what you were going to do, if needed. But it makes it much easier to be compliant.

ICT®: I’m reminded of a system for manufacturing cars called total quality control that Toyota introduced in 1961 where they said that anybody on that line in a factory can stop the conveyor belt anytime they see anything wrong. Now hospitals, I’m assuming are hierarchical institutions. Doctors, surgeons are at the top, or near the top. Hospital administrators, of course, such as yourself. Let me put it to you this way. Both of you are pretty high up there. And if someone on the environmental services (EVS) team spots a doctor not following hand hygiene that would have to be a pretty brave person to flag a doctor, no?

Tracey Odachowski: I’ve had an EVS worker correct me. It’s all about the culture you build. And we’re very adamant that peer coaching and checking is just as important as the response that you give to the person who coached you. And if you give an unacceptable response, where you become argumentative—anything where you take on that hierarchical stance of “don’t correct me.” It’s stopped. It is reported to that person’s leadership, and it’s corrected. And if you cannot abide by the culture where we can correct each other and have safety in correcting each other and not fear that retribution, then you need to find another place to work.

ICT®: I’m assuming this is more question for Tracey than it is for Linda, but whoever wants to answer it is fine. But COVID-19 has lit the fires of entrepreneurial drive in a lot of inventors. Are you getting hit with a lot of advertisements and marketing? Things that would supposedly help with hand hygiene? How do you separate what’s got potential from what doesn’t?

Linda Estep: That’s an excellent question. It really is. I receive phone calls and emails from vendors all the time. Infection prevention has a very close relationship with materials management. We work with them on everything from surgical instrumentation to the type of soap that we use throughout the system. So, we have a great relationship with them. We also have a system in place where if you want to bring a vendor in, you go through materials management process to get approval for the vendor because they’ll make sure that the vendor is solid. However they do that, that’s what they do. And so, I have presented or requested vendors through materials management and have been successful doing that. But if somebody just randomly calls me, or randomly stops by my office, I stop them. I don’t allow them to just walk into my office or email me or call me on the phone and start pitching. So, we do have a solid process in place, and it’s successful. And I always abide by that procedure.

ICT®: What was the high-tech help for hand hygiene that you bought and how were you sold on it?

Tracey Odachowski: We’re actually still in the process of evaluating the type of technology where you can have it automatically do the coaching of a staff member as they’re walking in and out of rooms. And what technologies we’ve got in place—and Linda helped me out on this one. We have already put technologies in place to make the auditing easier. And be able to be more mobile with the auditing. Auditing in the past has been very cumbersome. On paper, it’s hard to get a lot of audits in. And so, by making it a more electronic process, that makes it quite easy to be able to not only obtain the data as you’re out and about and doing so safely, not losing a piece of paper, but also to put all of the data together and be able to submit and look at our compliance.

ICT®: What happens on the ground?

Linda Estep: When the audits are being done?

ICT®: Yes.

Linda Estep: Some of our staff has access to tablets, and they can go into the program and put it in as they as they see it. And other people—I have to be honest—other people do still use the old-fashioned method of making tally marks on a piece of paper and then entering it into our system later. The problems associated with that include that the auditors, as good as they are, I’ve done many hand hygiene audits in my day, I still do hand hygiene audits, when I’m in the hospitals now. If they know who you are, they scatter. They know the infection preventionist. And we have a great relationship. The infection preventionists at each hospital have a great relationship with their staff. But there is still that tendency to wash your hands because you see the auditor and those don’t count. I won’t count somebody who just washes their hands because they see me. It has to be a reason and opportunity that they have in their job, that that’s a requirement when they should wash their hands. And then I’ll count it.

ICT®: I’m laughing because you bring up a point that several infection preventionists have brought up. That they feel a little bit like the hall monitor.

Linda Estep: You are.

ICT®: How do you know when the Hawthorne effect is going on?

Linda Estep: That’s an excellent point. And when we do send the secret shoppers where they were the staff does not know who the auditor is, or they don’t know that the auditor is auditing. And I would do that. I would go up to a unit sit down at a computer and start working because I have work that I can do on my computer. Looking at infections that may or may not be reportable. That type of thing. I would just sit in the unit. And while I was working, I would watch and do my audits that way. Now, a lot of auditors can’t go into the unit like that and comfortably sit down at the nurse’s station and do that like Tracey or I could. So, they go in. They try to blend in. But there are units, actually almost all units, when you walk in there, the nurses have a radar. They’re like, Who’s that? Why are they here? And if they don’t know they’ll come up and ask. “Who are you and why are you here?” Especially now that security is much higher than it’s ever been, particularly when you have hospitals with a burn trauma unit where there frequently the patient’s there because of violence. And sometimes that violence follows them into the unit or tries to follow them into the unit. So, you know those types of things. And nurses have that radar always. If you can’t blend in, you’re going to be clocked for doing a hand hygiene or some other type of audit, usually it’s hand hygiene. And then we do rotate the assignments for the auditors to try to alleviate that a little bit. We only work so well. And it’s very time-consuming for the person. And if you look at the thousands and thousands of hand hygiene opportunities that happened during patient care, during a 24-hour period, it’s a lot. One auditor trying to get people their audits done, it’s very ineffective volume wise. If you want to know the whole picture, you really do need that electronic thing. If there’s like a grid setup by the electronic systems. If you walk into the patient’s room, the sensor detects you crossing that threshold. And so, you have a certain amount of time, I think it’s about 60 seconds, to either sanitize your hands with an alcohol-based hand rub center or the sink. And if you don’t, then that’s documented as either compliant or not compliant. And so, the thousands of opportunities that happen in every department and every part of the hospital all day and all night is a lot. You need that big denominator to determine what your real compliance is. Because when we send the secret shoppers out, they come back with less compliance than the 90ish that we normally get reported by our manual auditors. The auditors that audit every month, they usually report around 90% compliance, sometimes even higher. So, we recognize that that is probably not accurate. But we still continue to coach one another, we still continue to raise the importance. Refresh that message so that it’s not white noise to try to raise compliance. But we really do hope for that electronic monitoring so that we can know what the compliance really is.

ICT®: You have the electronic monitor in place, and you’re looking at other high-tech solutions. I know that you, as a result of reading the article, that you’re also doing some tinkering with the system of hand hygiene and hand hygiene auditing. Is that a correct assumption?

Tracey Odachowski: Like where we get our audits from? Or where we input the audits?

ICT®: Just how you go about educating employees and reinforcing that education. Did you not make changes to the system that’s at the center of that?

Tracey Odachowski: Yes. We have a couple of campaigns. Our all hands on deck, which I described earlier, has been around for a few years now. And we still actively use that on a daily basis. And actually, when our auditors are out, if they notice that someone missed an opportunity, they say all hands on deck. And if the person corrects the opportunity they’re considered corrected and given credit for it. However, one of the other things that we’re doing now is a part of the CDC’s Clean Hands Count Campaign. So CDC has put out this Clean Hands Count Campaign. There are no trademarks around the signage around the pictures for it because they really want to get a nationwide campaign out there. We are implementing that campaign now as well, to kind of refresh what’s already been there, bring it back forth to mind. Have more recognized signage that anybody from the community would recognize no matter where they went since it’s the same type of campaign at any hospital. And we’re really excited to see how that might steer things even more. Linda and I were talking yesterday, actually, when we were observing some hand hygiene, in that that’s been one…. I mean, if you have to find a positive of this whole pandemic, is that hand hygiene in the community has been brought much more to the forefront. And that has been so refreshing. I think one of our poorest places that we saw in hand hygiene compliance was our patients and our visitors, despite what we tried to educate with them. And now, I mean to go into our emergency departments and see nearly empty hand hygiene containers and they’re having to be refilled every day or two, whereas it used to be days, weeks in between. It’s just wonderful to see that despite this horrible thing that’s been happening over the last year. We have had something positive come out of it. And hopefully, that will continue and be able to withstand all of this and that hand hygiene will become important for everyone, not just our health care providers.

Linda Estep: That’s such excellent information and such great points, Tracey.

Tracey Odachowski: Yes. We were standing in one of the in one of our hospital’s waiting rooms, looking at capacity, and there was a nearly empty canister of Purell in the waiting room, and we were so pleased. It’s the simple things, but it’s being used. Even my whole family, everybody’s going around with hand sanitizer attached to their keys, attached to their belt. They’re sanitizing their hands going through the grocery store. There are still additional opportunities, but it’s so much better than what it was. All of those opportunities count to help prevent infections. It’s just as important for our patients and our visitors to wash their hands as it is for our health care providers. We’re looking forward to continuing to leverage that, as well.

ICT®: This has become a bit of a difficult interview for me because you’re answering questions that I was planning to ask you. However, I’ll try to ask that question that you just answered in another way. And that is: How has COVID-19 changed the whole thought process around hand hygiene? Other infection preventionists have said to me that practices drift. Are you worried that practices will drift? And how much enlistment of patients in hand hygiene do you want? Would you like it to be some sort of formal thing?

Tracey Odachowski: Part of the clean hands campaign that we’re doing actually has some formal education with our patients and visitors as well. We’ve always had some things in place for certain things that we wanted to make sure that they used soap and water instead of hand sanitizer when required. We’ve had signage around our hospitals to remind people to not only wash their hands but ask their provider if they’ve washed theirs. But part of the Clean Hands Count Campaign involves refreshing some of that signage. And with the patients really focusing on hand hygiene throughout their day. So, providing Purell packets or some sort of hand hygiene packet on their tray at every mealtime. And the placemat. We’re looking at having that, you know, clean hands first. Make sure you wash your hands first before you start eating. So that we’re taking advantage even for those bed-bound patients to be able to have opportunities to do that. And your first question about whether or not it will stick? Will it drift? That was another part of our conversation of it. It’s going to be interesting to see. We saw this after 911. A lot of things changed after 911. And it was kind of the question was what would stay around. And there’s a lot of things that we have as a result of that. I think this is just as impactful. It’ll be interesting to see what things do stay around and what things drift. I’m hoping that our health care from across the country really leverages this and can use this to our advantage to keep that at the forefront of our communities so that we stay with this positive impact of hand washing, no matter where you are. And I think that’s why I’m very grateful for CDC creating this Clean Hands Count Campaign because it isn’t a different campaign at every hospital system or even every health care facility. It’s everywhere.

ICT®: Do you want to throw some numbers at me indicating how much your hand hygiene adherence has improved over the last year? Or maybe you weren’t able to crunch the numbers yet?

Linda Estep: That’s a bit hard to do that because I think that our numbers have always been high. Our compliance, at least from the auditors who spend a lot of their time doing those audits, and we already talked about some of the issues surrounding that. But the pandemic has definitely gotten people’s attention. It has gotten the staff’s attention. It’s got—as Tracey mentioned—the public’s attention. Our job as infection preventionists is to keep an eye out for any type of drift that we see. And we are continuously reminding people and encouraging the coaching, the peer coaching and peer checking to try to keep that culture intact and doing well despite the pandemic.

ICT®:What does all hands on deck stand for? It’s a motto, right?

Tracey Odachowski: It’s kind of a safe phrase. Again, just so that you’re not saying, “Hey Linda. You didn’t wash your hands.” That feels more negative. And so that can elicit a more negative response from the person who’s receiving it because it doesn’t feel good. Whereas all hands on deck is safe. Only the people who’ve been trained on it kind of know what it means. And we kind of tend to use it … it’s always been kind of a catch phrase out there. When you say that it doesn’t initiate that negative response on the part of the person who is receiving it. We really kind of drove it in as is a pure checking tool to make it safe. It was just to take that negative connotation out of you didn’t wash your hands.

Linda Estep: And another thing that Tracy brought up earlier, too, is that is the importance of the correct response from the person being coached. I had a couple of incidences where I washed my hands with soap and water inside the patient’s room prior to exiting. The door was open. I wash my hands with soap and water. I tried to follow the proper procedure, dry my hands, discarded my paper towel, walked out of the room. And somebody in the unit would see me coming out of the room who hadn’t seen me wash my hands. And they looked at me and said, “all hands on deck.” And so instead of saying I just washed my hands in the room, I said, “Wow, thanks for the reminder.” And I used the alcohol-based hand sanitizer that was right there just to keep them encouraged about coaching and having that correct response. And there are other people in the unit watching and hearing what’s going on as well. It’s really important, somebody if you have a bad response, somebody watching is going to go, “I’m not going to say anything next time that happens.” You have to really respond correctly. And it’s really important, I think—and forgive me for saying this—but I think the most negative responses that I’ve had are from physicians. And so thankfully, we have a lot of support from our C-suite, our leadership, our vice president of medical affairs at each hospital, who is a physician. So, when I have had trouble with physician responses about lack of hand hygiene, lack of wearing PPE, any type of transmission risks that I see them doing, I will go to the VPMA and let him or her know what was happening and let them approach from a peer … actually they’re higher than the physician. Sometimes you’ve got to get those veeps involved. It’s really important to have the correct response. And there are lots of physicians who do respond correctly. They are on board. They want this thing to develop and to continue. I was in a unit one day and I stood and I said “all hands on deck” to a physician who was like four rooms down from where I was. And he turned and he looked and he grabbed the hand sanitizer, and he waved at me with his while he was sanitizing his hands like, “Hey, thanks.” You know, the thumbs-up. So that does happen too. It’s not all bad.

This interview has been edited for clarity and length.