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Quality Update - Data for the doubters

Winter 2011

Data for the doubters

Date: January 20, 2011

We're constantly reminded that cleaning hands saves lives, but it's nice to see direct evidence that it works.


Angela Feurer
Culturing caregivers’ hands was one of the methods used by Angela Feurer to show how easily bacteria can spread. Still, some caregivers on her unit wanted additional proof.
Photo by Keith Weller

As the most vocal advocate of hand hygiene on the neurosciences critical care unit (NCCU)at The Johns Hopkins Hospital, Angela Feurer has followed a strategy of helping her colleagues to see the invisible.

Two years ago, in a demonstration of how easily caregivers could acquire pathogens, Feurer invited staff to slide their fingertips across a culture medium. Before doing the exercise, most had only touched keyboards or phones, rather than handling patients, since their previous hand cleaning. Yet, as if emphasizing her point, the funk growing in these cultures “actually made my office stink,” Feurer says.

In another exercise, Feurer, the unit’s assistant nurse manager, surreptitiously sprinkled countertops and other surfaces with a powder that is visible only under a black light. Later, she used the light to show caregivers how they had spread the powder throughout the unit and onto their clothes.

“At this point, I think the buy-in from our staff began,” she says. Yet Feurer continued to face resistance from some caregivers who still didn’t see the connection. They asked, Where is the proof that cleaning hands so frequently truly prevents disease?

She now has an answer, courtesy of a recent study of Hopkins’ adult intensive care units by the Hospital Epidemiology and Infection Control (HEIC) department. The analysis found that, as a hand-hygiene initiative boosted compliance by more than 50 percentage points over three years, transmission of methicillin-resistant Staphylococcus aureus (MRSA) dropped by 42 percent, and transmission of vancomycin-resistant enterococci (VRE) went down by 31 percent.

These reductions prevented approximately 15 MRSA or VRE health care-associated infections and between one and five infection-related deaths in the ICUs, according to the estimates. Because they represent only two pathogens and are limited to critical care units—the only areas where patients are systematically screened for pathogens throughout their stays—the results are likely just a fraction of the total impact of the hand-hygiene improvement.

Trish Perl, senior epidemiologist for the Johns Hopkins Health System, acknowledges that past studies have shown that hand cleaning stops transmissions and infections. But she still occasionally encounters skepticism from Hopkins clinicians who point out the age of those studies, as well as the “idiosyncrasies” of their hospital’s environment—a high rate of community-acquired MRSA and a very sick and vulnerable patient population.

“Our recent data just reinforces that, yes, hand hygiene works within our institution,” says Perl.

The results, she hopes, will show the hospital community that the organization’s extensive efforts to improve hand-hygiene have been worthwhile.

This extensive and multifaceted approach, developed by HEIC and the Center for Innovation in Quality Patient Care, combined communications and education about hand hygiene with rigorous monitoring of compliance and concrete steps—such as installing more hand-sanitizer dispensers outside patient rooms—to remove barriers that impede infection control practices.

Performance data, grouped by unit, department, provider type and other categories, are circulated monthly throughout the hospital to keep leaders and caregivers engaged in the effort. The results have fostered a healthy competition between units and departments.

Key to the program’s success thus far was providing ongoing data feedback that revealed to members of the hospital community that they weren’t as thorough about hand-hygiene as they might have thought. Prior to this, some units believed that they were 90 percent or more compliant in their hand-hygiene practices. But after the hospital introduced a “secret shopper” model of surveillance, in which trained observers covertly record hand-hygiene behavior, units often found that their scores were substantially lower.

“If you work at an institution that believes it is at 80 percent or 90 percent, nobody is interested in improving,” says Hanan Aboumatar, education and research associate with the Center for Innovation and an architect of the hand hygiene promotion program, known as WIPES.

Polly Ristaino, HEIC’s associate director, says that some hospitals ask providers, who can be biased, about their hand-washing practices. Others use easily identifiable infection control staff to collect the data, “so of course people wash their hands when an infection control nurse shows up.”

At Hopkins, Ristaino says, doubters often became convinced of the data’s validity after their units began to monitor themselves internally.

Feurer says one step that helped her unit to improve was arranging to get more detailed and timely information from the hospital’s secret shoppers. The shoppers’ observations are typically compiled and sent to units every month, but Feurer arranged for them to give her a copy of their worksheets immediately after they had visited the NCCU. These observers also describe the caregivers’ appearance (if they don’t see the name), where they were standing and other details, and then give a copy of that data immediately to Feurer.

 She uses that information to identify caregivers and give them real-time feedback, either thanking them for their compliance or reminding them of hospital policy. Revised by the hospital in early 2008, the policy requires hand cleaning upon entering and exiting patient rooms, as well as in other instances, such as after contact with bodily fluids.

Feurer also posts the unit’s monthly results on a bulletin board in the staff lounge. And, in keeping with her strategy of making things visible, she includes on the board the names of those who were observed following the hand-hygiene policies and those who were not. To Feurer’s surprise, she hasn’t met resistance to this practice, she says.

Her unit was among the hospital’s most improved in hand-hygiene compliance for one quarter last year, and Feurer hopes that the recent data on transmissions will spur caregivers to do even better.

“I wish we had these findings two years ago when we started our hand-hygiene efforts, but I’m so glad we have them now,” she says.  

Visit the Center for Innovation's website for tools, resources and training videos on hand hygiene

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