It’s one of simplest ways of preventing deadly infections in hospitals, but it has been one of the most difficult to enforce.
Hand washing — even quick swipes of anti-bacterial foam and gel — remains an often-forgotten practice at the nation’s hospitals, including in five of Lee Memorial Health System’s primary treatment centers.
In a comprehensive review of staff hand washing within the health system, undercover observers found that, overall, three of every 10 staffers were not cleaning their hands properly before coming into contact with patients. Among the worst offenders: Doctors, who had an average hand-washing “compliance” rate of 51 percent.
Steve Streed, who oversees the organization’s infection control efforts, said he is not the least bit surprised. He views it through a glass-is-half-full perspective, arguing that the results are largely positive because physicians at other hospitals commonly score well below 50 percent.
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“I have to tell you, when I compare these data to other institutions, … I think we’re starting at a notch above,” Streed said.
Nurses, physician assistants and physical therapists had among the highest compliance rates, generally scoring between 75 and 94 percent, the report shows. Dietary staffers were near the bottom, with an overall rate of 27 percent.
One small surprise: Lee Memorial Health System had roughly the same compliance rates even during the night shifts, when staffers are far less likely to be observed, Streed said.
Heath care-associated infections account for an estimated 90,000 U.S. deaths a year and add up to $7 billion annually to the nation’s health care bill. And hands, according to the Centers for Disease Control and Prevention, are the primary delivery vehicle.
The health system has long monitored staff hand-washing, particularly in the intensive care units, and commonly reminds its employees to do so.
Hand-sanitizing foam and gel are at hundreds of locations throughout the organization’s hospitals and clinics, and signs even chide visitors about keeping their hands clean.
This review took things a step further by asking staffers to act like secret shoppers and monitor their colleagues in other departments as they visited them between July and September.
Results were recently made available to the organization’s board of directors and to the organization’s 10,000 employees.
“It’s a peer pressure thing,” said health system spokeswoman Mary Briggs.
Germans, germs
Studies show wide variation in hand-washing practices, possibly the result of organizations’ different safety cultures and wildly different ways of checking for it. But the results do seem to generally bear out the point made by Streed, the health system’s infection control expert, about poor compliance elsewhere.
One 2004 study in Geneva found that 36 percent of doctors washed their hands when there was a high risk for transmitting germs. Another that year at a teaching hospital in Heidelberg, Germany, found that nurses did better at it (67.9 percent compliance) than doctors (57.5 percent).
Earlier studies elsewhere have shown hand hygiene rates as poor as 8 percent among medical staff.
One of the most recent case studies involved Johns Hopkins Hospital in Baltimore, a 1,035-bed teaching facility. Its three-year program, which included the “secret shopper” model of compliance testing, eventually added more than a third demonstrating proper hand-washing — from 38 percent to 62 percent among doctors.
The CDC estimates the average rate is roughly 50 percent at all U.S. hospitals.
Other systems
NCH Healthcare System, Collier County’s largest hospital system, has conducted nearly 8,000 staff audits — self reported and from the reports of “secret shoppers” — in the past few years, said Marie Commiskey, who leads NCH’s infection control efforts.
While the private, not-for-profit organization would not release a full breakdown of staff compliance, its overall rate for all employees is about 77 percent, Commiskey said. Lee Memorial’s overall rate is 70 percent, though it’s unclear if how much different reporting methods factor into the scores.
Family Health Centers of Southwest Florida — a nonprofit with physician and dental offices throughout Lee, Charlotte and Hendry counties — recently started its own effort.
The organization, which has more than 215,000 patient visits a year, claims to have an average hand-washing compliance rate of about 94 percent, based a sampling of direct observation and patient surveys.
It’s a rate that comes from constant reminders to staff and encouragements to patients to call out staffers who don’t, said spokesman Bob Johns. Still, it’s starkly higher than most large hospitals. Johns explains it this way:
“At hospitals they really are flying from room to room, procedure to procedure,” he said. “So, comparing us to hospitals is like comparing apples to oranges.”
Coaching coming
Now that the health system knows about its hand-washing issues, the next step will be better staff safety coaching, Streed said. Eventually, compliance may become part of individual job performance review process, he said.
NCH has no formal disciplinary formula for this, but problem staffers are typically told to mend their ways, Commiskey said.
Hospitals elsewhere have threatened disciplinary action against repeat offenders. Though it has been suggested here, no such penalties are on the table, administrators say.
Richard Akin, chairman of the health system’s elected governing board said he wants to avoid “punitive” measures against employees.
“I think that our employees want to do it right,” Akin said. “They want to have the safest environment — I haven’t run into a single employee who hasn’t wanted that. But I also think we need to hold people accountable.”