Sunday, April 09, 2006

I didn't see you wash your hands.

Your life is in hospital workers' (clean) hands
Washing hands can save patients' lives, but hospital workers still don't do it enough
By Peter DeMarco, Globe Correspondent July 13, 2004
Hand-washing is perhaps the easiest, lowest-technology way to prevent the spread of germs, but even the highest-tech hospitals can't seem to get their doctors and nurses to do it enough.
Nearly two years ago, the US Centers for Disease Control and Prevention told every hospital in the country that their doctors, nurses and other health-care workers needed to do a better job of washing their hands to cut down on patient infections. Several Boston hospitals took the advice and launched all-out campaigns to encourage more hand-washing, plastering intensive care units with educational posters, throwing pizza parties for units that improved their hand-washing rates and posting observers to count the number of times workers missed opportunities to wash up.
But Brigham and Women's Hospital, which has one of the most successful hand-hygiene programs around, still only reached 80 percent compliance in some intensive care units -- and then only while it was offering free movie passes to the units that kept their rates high.
''Without that incentive, [the rates] have sort of come back down," said Dr. Deborah Yokoe, supervisor of Brigham and Women's infection control unit. ''The question we're really facing now is: How do we get over this hump?"
Hospital workers have known since the mid- to late-19th century that it's important for them to wash their hands. In 1847, Dr. Ignac Semmelweis was pushed out of a Viennese hospital for demanding that workers wash hands, but his then-radical notion -- that hand-washing would reduce the number of mothers dying after childbirth -- caught on a few decades later.
The CDC's 2002 voluntary hand-washing guidelines, including how and when workers should wash their hands, followed a study by infection control experts at the University of Geneva Hospitals that found a 50 percent drop-off in patient infections after modest increases in hand-washing by staff members.
According to infection experts and federal statistics, as many as 5 percent to 10 percent of US patients contract an infection while in the hospital, resulting in about 2 million infections per year -- leading to 90,000 deaths -- at a cost of $4.5 billion.
But getting doctors and nurses to become obsessive hand washers is proving difficult.
For most, it's a question of competing priorities. Quick-drying hand gels that kill bacteria without need of soap and water are now standard fare in 95 percent of US hospitals. But still, at 30 seconds per hand wash, busy hospital workers who constantly jump from patient to patient could spend 10 minutes per hour washing their hands, leaving them less time to do other important tasks, like examining patients and double-checking drug doses.
''It's not just that you're busy: you're busy doing things that are all important for the patient," said Dr. Atul Gawande, a general surgeon at the Brigham, and a writer who has expounded on the importance of hand-washing. ''Of all the things you have to do, hand-washing will slip down on that list."
Sterilization has long been the norm in operating rooms, but that thinking doesn't necessarily carry over to other areas of the hospital, where seemingly innocuous tasks such as picking up a patient's chart, touching your tie, or typing on a computer keyboard can easily spread germs.
Susan Marino, an infection control practitioner at the Brigham who spends hours each month counting the number of times hospital workers wash their hands, said workers can be lulled into thinking that latex gloves offer enough protection. But if they inadvertently touch dirtied gloves as they're taking them off, all the germs end up on their bare hands, and they need to wash again, she said.
Standing in an ICU unit one recent afternoon with her clipboard in hand, Marino observed as a half-dozen workers failed to wash their hands either before they put on gloves or after they peeled them off.
''Surgeons would consider it absolutely unacceptable if fellow surgeons didn't do a thorough scrubbing," said Dr. David Hooper, chief of infection control at Massachusetts General Hospital, whose hospitalwide compliance rates are above 60 percent, up from 40 percent a few years ago. ''You've got to get a critical mass where it becomes self-reinforcing; where it becomes professionally unacceptable not to wash."
Another problem infection control experts face as they roll out hand-washing initiatives is that no one knows for sure just how many infections better hand hygiene will eliminate. The Swiss study showed that boosting the compliance rate from 48 percent to 66 percent hospitalwide cut patient infection rates in half over a four-year period. But better hand hygiene won't stop all infections: Intravenous lines, surgical sites, catheters and ventilator tubes will always be susceptible, and germs are also spread by visitors and the patients themselves, not just hospital workers.
Dr. John Boyce of the Hospital of Saint Raphael in New Haven, who coauthored the CDC's hand-washing guidelines, said most hospitals probably would see a significant reduction in infections if they could maintain an 80 percent or 85 percent compliance rate.
Realizing that change takes time, infection control experts have been careful about pushing workers too hard to improve their washing rates, choosing to entice them with prizes and praise rather than penalizing them for failing to wash.
''Penalizing just doesn't work," Yokoe said. ''It makes people more defensive and it makes them less likely to change their behavior. We absolutely do not want to become the infection control police."
The other battle hospitals are up against is one they just may never win -- human nature. Gawande, who put forth a call for better hand hygiene in an article in the New England Journal of Medicine this winter, said even he, at times, simply forgets to wash.
''I'm in the midst of writing this article [on hand-washing]. I'm being as scrupulous as I can be, and I still blew it. Or a patient reaches out to shake your hand, and you may find it strange to say, 'Oh, I've got to wash my hands first."'
Still, infection control experts at a handful of area hospitals say they have been able to increase their compliance from roughly 40 percent to 70 percent with outreach efforts. To keep it going up, Yokoe said she intends to meet with staff members from one of her hospital's intensive care units today for a hand-washing brainstorming session.
At Beth Israel Deaconess Medical Center, infection control director Dr. Sharon Wright said she hopes that ICU doctors and nurses will begin to take ownership of their hand-washing compliance, and begin self-monitoring their units some time this month.
And if they need a few extra sets of eyes, Wright said, patients can speak up, too.
''Initially it was a rare patient who was aware of [hand washing], but now they may bring a bottle of hand gel on the T. They can buy them in drug stores.
''It wouldn't be unusual anymore for a patient to ask a doctor, 'I didn't see you wash your hands."

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