Published in the January 2013 issue of Today’s Hospitalist
HANDWASHING “SPIES.” Flashy screen savers. Strategically-placed sanitizer dispensers. All were part of a multifaceted initiative to improve hand hygiene that had Dartmouth-Hitchcock Medical Center in Lebanon, N.H., throwing just about everything, including a portable sink, at the problem. The combined strategies helped the hospital more than double its hand-washing compliance rates.
Before the initiative began in 2006, says epidemiologist and associate professor of medicine Kathryn Kirkland, MD, those rates barely cleared 40%. The hospital’s lackluster history with hand hygiene had many of her medical colleagues skeptical about efforts to do better, but Dr. Kirkland refused to be dissuaded. “Hand hygiene adherence is the single most important factor in reducing the risk of health care-associated infections,” she explains.
To get results and overcome the skepticism of her colleagues, Dr. Kirkland identified five interventions to improve hand hygiene. She then tailored those to specific units in the hospital and organized subgroups of leaders to implement each intervention.
Over the course of three years, compliance rates first hit 87%, then 91%, while the rates of hospital-acquired infections fell by at least one-third, according to results published online in July 2012 by BMJ Quality & Safety. Dr. Kirkland spoke to Today’s Hospitalist about the initiative and its results, and the need to play the long game if you want to permanently improve hand hygiene.
How did you start?
Initially, we made sure that clinicians knew what they were supposed to do, and we reminded them that this was a priority. And we didn’t try to manage everything centrally. Instead, we spoke to individual units about systemic obstacles to hand hygiene and the best ways to adapt measures on specific floors because one size just doesn’t fit all. Though there wasn’t much physician leadership beyond me, the unit leaders were very encouraging. Our nursing leader was also a champion.
We then assigned two nurses to observe handwashing routines, a task that took a few hours per week. Occasionally, we’d ask students to help with the observations, so that we had a minimum of at least 20 observations per unit per month. Between 2006 and 2008, we doubled the number of monthly observations, from 244 to 498.
How effective were the observers?
After a while, clinicians recognized the observers. This had little impact on low-performing units, which didn’t seem to care whether or not they were being watched. But we figured that if being observed made some units perform better, then it was part of the solution.
That points to another intervention: measurement and feedback. We posted unit-specific reports on hand hygiene compliance monthly on the Intranet, causing a four-fold increase in Web site visits. There was some friendly competition between units, but most were more concerned about whether or not they were hitting their goal of 90% compliance.
What other interventions did you use?
We started off putting hand sanitizers in the most opportune places and increasing the number of dispensers available. Interestingly, hand sanitizer locations varied by unit based on their specific workflow, which proved successful for staff who stayed on one unit all day.
But this made it more difficult for people who worked on different units because the sanitizers were in different places. Still, hand sanitizer refills for wall-mounted dispensers increased 37%, and the number of desktop dispensers increased 86% over the three years. We also tracked hand sanitizer use so units could see how they were doing over time and in comparison to others.
How about education and training?
We presented two educational opportunities during the initiative. The first was a portable sink where workers could demonstrate handwashing competency and earn certification. We rotated the apparatus through the hospital, and it was as much about publicity as anything else.
The second was an electronic learning module that is now incorporated into the online learning program required annually for staff. It is also part of student and new employee orientation at Dartmouth.
We also had interventions geared to marketing and communication. We distributed 11 posters sequentially throughout the campaign. The posters included information about hand hygiene and its links to infection transmission, as well as information on local successes. We also distributed screensavers on inpatient work computers that flashed hand hygiene messages. And finally, we had two articles printed about the initiative in internal hospital publications and the local newspaper.
According to the study, only nonphysician staff achieved the 90% target. Why is that?
It can be partly attributed to system-level failures, but there is also a lack of strong medical leadership outside of infectious disease in terms of hand hygiene.
We also targeted many improvements at nurses, not physicians. For example, we put hand sanitizer where it was convenient for the units, which meant that doctors who work on multiple floors might have a harder time finding them. And measurement and feedback also targeted units, so we didn’t report, for example, how obstetricians were doing compared to orthopedists.
Today, we are working to maximize physician-level feedback and systems geared toward them. We need to understand how doctors do their work to make it easier for them to comply with hand hygiene protocols. We did notice increased buy-in from some skeptical physicians as the initiative went along. Physicians who saw the reduction in hospital infections found that to be powerful information.
This initiative took three years. Did you need that much time?
It was very important to do this over a long period of time. We had to transition from the “campaign mentality” to the normal business routine. The entire culture has shifted to a focus on continuous improvement as a result of this initiative. People understand that it’s not just a problem of the day “it’s every day.
What advice would you give other hospitals looking to implement such a program?
Start with measuring the status quo. You must understand how your system is working in respect to hand hygiene. What do people know or not know, and what are their attitudes? Next, make products widely available and engage people at the local levels. There must be solid leadership and ways of holding units accountable.
And once the project begins, look for patterns of failure vs. single instances of failure. Very few people turn up in the database more than once. If you see someone showing up repeatedly over time, you should intervene. When you show them data that they are outliers, they usually move back to the norm. Most people want to do the right thing.
Ingrid Palmer is a freelance health care writer based in Evergreen, Colo.