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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 amajor healthcare problem. A performance improvement intervention project wasinitiated in October, 2000 to assess the impact of a multi-dimensional strategyto improve hand hygiene compliance at a tertiary-care hospital. The interventionproject was completed Oct. 15, 2001, and thus far has demonstrated remarkableimprovements in compliance.
The key to the improvement we have seen has been the introduction of amulti-dimensional approach that recognizes the needs of both HCWs and theirpatients. Thatcher Pharmaceutical Co. of Salt Lake City provided free quantitiesof GelSan, an ethyl alcohol-based hand sanitizer gel withmoisturizers for the duration of the project. Thatcher supplied the gel indispensers that were placed at the entrance to each room in the interventionunits.
After enlisting the support from nurse managers and unit medical directors,meetings were held with HCWs to explain the project and provide the latestinformation on the efficacy of alcohol-based gels. Workers were instructed thatthe alcohol gel could be used for hand hygiene whenever hands were not visiblysoiled with body substances. Since gels do not mechanically clean the hands, atraditional 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 theneed to perform hand hygiene.
Based on the experience of infection control personnel and documentedevidence from several years of microbial studies, extra isolation precautionswere removed from the intervention units for some organisms, specifically, therequirement to isolate patients having vancomycin-resistant Enterococci (VRE).Hand hygiene, when performed consistently and well, has been shown to be veryeffective in decreasing the spread of organisms between patients. Body substanceprecautions require the standard use of barriers, such as gloves, masks/goggles,and gowns, based on the intervention with the patient, not based on thediagnosis. These two interventions encompass the unknown or unrecognized carrierin addition to the recognized carrier of VRE, making additional precautionsredundant. This saves time and money for the facility, and the patient benefitsby 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 thehospital's epidemiology physicians met regularly with medical directors,residents, and house staff. The HCWs were provided with current compliance andtransmission 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 theelements mentioned above. Two other areas, where none of the interventions wasinitiated, had compliance measured in the same manner as the case units.Compliance was measured by trained observers who visited each unit on a randombasis. For about an hour on each unit, the observers recorded the activities ofthe HCWs in terms of whether or not the worker performed hand hygiene (asoap-and-water wash or waterless wash with GelSan) when approaching or leaving apatient. To date, more than 12,000 observations have been made.
After 6 months of successful outcomes from the initial period, the third andfourth units were fully incorporated into the project and received the sameinterventions. Thatcher Pharmaceutical provided additional dispensers withGelSan so that they could be conveniently located and available toall HCWs when they enter or leave a patient's area. After being incorporatedinto the project, the third and fourth units were compared to the other testunits.
Over a 9-month period, an active, multi-dimensional campaign resulted in asignificant increase in hand hygiene compliance at our institution. The initialunits, ICU #1 and ICU #2, went from a compliance rate of 27.5% to 49.3%. Thesecond 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 ThatcherPharmaceutical to include our feedback into the design of the product, toinclude a professional infection control perspective, and to improve acceptanceof the gel with various medical staff departments. The gel began to catch onwith our staff, and other units outside of the study adopted GelSan.
Instituting a change in human behaviors must often take place in incrementalsteps. For years, the hospital emphasized hand hygiene using soap and water. Weare now urging the use of GelSan whenever hands are not visiblysoiled; soap-and-water hand hygiene must still be used if hands are visiblysoiled. We estimated that more than 80% of the hand-hygiene opportunities werewhen HCWs' hands were not visibly soiled.
We anticipated some resistance to change. Experience with alcohol products inthe past left HCWs concerned about their hands drying out and cracking orchapping. Regardless of instruction about how the use of soap and water canactually damage the skin over time--leaving places which harbor pathogens--HCWshave been taught and have relied on this method for a lifetime of patient careand self-care. However, it was evident by our observations that using analcohol-based product specifically designed with emollients that preservethe skin quickly gained acceptance. During the study, we have measured the rateof soap and water hand hygiene vs. waterless hand sanitizing. Figure 2demonstrates the acceptance of the new method.
Over a 9-month period, our multi-dimensional campaign has resulted in asignificant increase in hand hygiene compliance at our institution. The use of agel designed to preserve skin integrity was a key factor that helped to increaseour compliance. We also found that educating staff about the importance of handhygiene and placing gel dispensers in high-traffic areas helped increase thefrequency of both soap-and-water and alcohol gel washing in our facility. Futureprojects 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.