Us­ing mil­i­tary-style dis­ci­pline to en­force hand hy­giene stan­dards

Modern Healthcare - - BEST PRACTICES - By El­iz­a­beth Whit­man

After see­ing a spike in hos­pi­ta­lac­quired in­fec­tions, lead­ers at Na­tion­wide Chil­dren’s Hospi­tal de­cided they needed to take dras­tic ac­tion.

The 604-bed pe­di­atric hospi­tal in Colum­bus, Ohio, had ex­cel­lent hand hy­giene, ac­cord­ing to self-re­ported sur­veys. But when lead­ers in­stalled ob­servers to covertly mon­i­tor hand­wash­ing and hand san­i­ti­za­tion habits, com­pli­ance was less than 60%.

“So we knew that what we were do­ing to date was not work­ing,” said Dr. Ter­rance Davis, as­sis­tant to the chief med­i­cal of­fi­cer at Na­tion­wide Chil­dren’s. “We were look­ing for some way of dra­mat­i­cally get­ting hand hy­giene high on ev­ery­one’s agenda.”

Dirty hands are linked with health­care-ac­quired in­fec­tions, which are both deadly and costly. In 2011, nearly 722,000 such in­fec­tions oc­curred in hos­pi­tals, and about 75,000 pa­tients with those in­fec­tions died. Th­ese in­fec­tions cost hos­pi­tals any­where from $28 bil­lion to $45 bil­lion an­nu­ally.

Proper hand hy­giene is con­sid­ered one of the most ba­sic el­e­ments of in­fec­tion con­trol, but the av­er­age health­care provider cleans his or her hands less than half the num­ber of times they ought to, ac­cord­ing to the Cen­ters for Dis­ease Con­trol and Pre­ven­tion.

To ef­fec­tively draw its staff’s at­ten­tion to hand hy­giene, Na­tion­wide Chil­dren’s ul­ti­mately de­cided on a stand-down, an in­ter­ven­tion bor­rowed from the mil­i­tary. In the 15-minute drill, which took place twice— once in the morn­ing and once in the even­ing—on a single day in spring 2010, ev­ery­one and ev­ery­thing ex­cept es­sen­tial pa­tient care ground to a halt.

Ev­ery­one on a unit, from aides to at­tend­ing physi­cians, con­vened and dis­cussed an ac­tion plan de­liv­ered by a man­ager, Davis said. And if they, as units and as in­di­vid­u­als, did not meet 90% com­pli­ance rates or were caught fail­ing to com­ply, they would have to meet with the chief med­i­cal of­fi­cer or chief nurs­ing of­fi­cer, or their de­sig- nates, to ex­plain why.

“We didn’t know how ef­fec­tive that would be,” Davis said. “It turns out it’s pretty em­bar­rass­ing to be called to the prin­ci­pal’s of­fice to ex­plain why you’re not do­ing your job.”

Even be­fore the stand-down, there was a lot that hospi­tal lead­ers had to change to en­sure that ev­ery­one—not just nurses and doc­tors but also em­ploy­ees work­ing in food and clean­ing ser­vices—could com­ply with proper hand hy­giene. That en­tails clean­ing one’s hands be­fore en­ter­ing and after leaving a room, ei­ther with soap and water if hands are soiled or with hand san­i­tizer if they’re not—whether or not the hands will be touch­ing a pa­tient.

But dis­pensers of san­i­tizer gel were in­con­ve­niently placed around the hospi­tal. They were in­side pa­tients’ rooms and lo­cated be­hind the door. So the hospi­tal re-in­stalled those dis­pensers out­side nearly every pa­tient room, along hall­ways and out­side el­e­va­tor en­trances.

“We had to make it re­ally, re­ally, easy to find that gel,” Davis said.

Also be­fore the stand-down, hospi­tal lead­ers con­vened a manda­tory safety sum­mit of med­i­cal and nurs­ing unit di­rec­tors and other de­part­ment heads. There, di­rec­tors were told they needed to come up with an ac­tion plan to im­prove com­pli­ance.

Within a month of the stand-down, com­pli­ance rates hit 90%, and they’ve stayed that way for six years. Davis and his col­leagues pub­lished the re­sults of their in­ter­ven­tion in the Jour­nal of Pa­tient Safety. Davis said separately that health­care-ac­quired in­fec­tion rates had dropped sig­nif­i­cantly in sev­eral cat­e­gories, in­clud­ing sur­gi­cal site in­fec­tions and cen­tral line in­fec­tions.

It was not the dra­matic stand-down alone that was so ef­fec­tive. The en­tire cul­ture shift was well-en­gi­neered and planned out, Davis said, and hospi­tal lead­er­ship took it se­ri­ously. The fact that staff and providers were heav­ily mon­i­tored helped en­force the new cul­ture of strict ad­her­ence to hy­giene pro­to­cols, too.

“That whole com­bi­na­tion of things—tak­ing it se­ri­ously, lead­er­ship en­gage­ment and ac­count­abil­ity—re­ally had some mean­ing to it,” Davis said.

One way the hospi­tal knew the new ap­proach was work­ing was when a spe­cific brand of feed­back be­gan trick­ling in. “We be­gan get­ting a lot of com­plaints of skin ir­ri­ta­tion,” Davis re­called. “We had to go through sev­eral dif­fer­ent types of clean­ing gel un­til we got one that had enough lo­tion in it.”

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