Hand Hygiene: Moving Toward the Five Moments
January/February 2013
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Hand Hygiene
Moving Toward the Five Moments
Much has been written and discussed about the Five Moments for Hand Hygiene from the World Health Organization (WHO). Most healthcare workers agree that doing hand hygiene at those five events is important to improve patient care but not everyone agrees on the real-world implementation.
The approach defines the key moments when healthcare workers should perform hand hygiene. This evidence-based, user-centered approach is designed to be easy to learn, logical and applicable in a wide range of settings.
The five events are:
- before touching a patient,
- before clean/aseptic procedures,
- after body fluid exposure/risk,
- after touching a patient,
- after touching patient surroundings.
According to research findings by Virginia Commonwealth University physicians, high compliance with hand hygiene and focusing on other simple infection control measures on medical, surgical and neuroscience intensive care units resulted in reduced rates of methicillin-resistant Staphylococcus aureus (MRSA) infection by 95 percent in a nine-year study.
The VCU team employed a horizontal infection prevention strategy of high compliance with hand washing that prevents not just MRSA, but all infections that are transmitted via contact. Patient safety was the key benefit to this approach. For healthcare workers to be able to comply with these Five Moments, it is essential that hand hygiene products be available to the staff inside the patient room and at the point of care.
Jane Kirk MSN, RN, CIC, Clinical Manager, GOJO Industries, Inc. Akron, Ohio explains, “The point of care is defined as that place where the patient, the healthcare worker, and the care or treatment involving contact with the patient or his/her surroundings come together. This requires that hand hygiene products be easily accessible and within arm’s reach of where patient care or treatment is taking place.”
But just having the facilities to perform hand hygiene conveniently available isn’t the same as having all caregivers use those facilities. Anecdotal evidence shows that a somewhat cavalier attitude is often present in the non-critical care units—and all too often in critical care as well. If the housekeeping staff, the food service delivery, and even medical staff members enter a patient’s room but stay for less than a minute—or perhaps just a few minutes—it is rare for them to take the time and effort to perform hand cleaning.
“I am not familiar with any time rule which determines how long a healthcare worker can be in a room before needing to clean their hands,” admits Kirk. “The Center for Disease Control and Prevention (CDC) and the World Health Organization Hand Hygiene Guidelines only recommend specific events when a healthcare worker should clean their hands.”
Frequent use of some hand hygiene products can cause skin irritation in healthcare workers. The two major types of skin reactions associated with hand hygiene are irritant contact dermatitis and allergic contact dermatitis.
Symptoms of irritant contact dermatitis include dryness, irritation, itching, cracking and bleeding. Allergic contact dermatitis is rare and could include reactions from other products such as gloves and can include respiratory symptoms as well as localized reaction. There are many steps a healthcare facility can take to minimize these issues. Kirk points to selecting less irritating hand hygiene products as a first step. “There are several studies that support alcohol-based hand rub (ABHR) as less irritating than frequent use of soap and water. Staff acceptance of the products provided is essential. All new products under consideration should be tried by the staff before purchasing.”
Staff may need reminders to avoid practices that increase the risk of skin irritation. Some of these include not washing hands with soap and water before applying an alcohol product, or not donning gloves while hands are still wet. Another reminder might be that healthcare workers should protect their hands from the elements with outdoor gloves when living in harsh climates.
Although many hand sanitizers contain emollients, healthcare workers should also be provided with hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or hand washing.
Obviously, healthcare workers in hospitals are the ones who most frequently use hand cleaning products. But others visiting the patient’s room—and the patient, too—should be cautioned about hygiene requirements. Visitor and patient hand hygiene are areas of infection control that still need to be explored.
“All non-medical visitors need to know that it is proper for them to use the hand sanitizer. Possibly they need an invitation conveyed by signage,” notes Kirk. “Sometimes visitors do not recognize a brand or dispensing method as a hand hygiene product. Having a recognizable brand and invitational signage can help encourage non-medical visitor usage. A recent study showed that visitor hand hygiene improved significantly when a combination of a desk sign mandating that all visitors use ABHR with a free standing ABHR dispenser placed directly in front of a security desk were implemented.”
Healthcare workers, especially the nurses, tend to watch hospital-oriented television shows if only to catch the characters in errors of procedure. And catch them they do. How many times have you seen a doctor, much less a nurse, in a TV show wash their hands? How many hand hygiene stations are shown in TV hospitals? Doctors and nurses enter and leave rooms and treat patients without ever cleaning up before or after. And these are the role models!
Role models can be valuable in changing the culture surrounding infection control. But as Paul Alper, Vice President, Strategy and Business Development for DebMed, Charlotte, NC puts it, “I think there are three important elements to create a culture in which hand hygiene is a habit for all. And that’s really what we’re talking about, it has to becomes part of the culture. First of all, leadership has to make it a top priority for the organization. It has to be something that is spoken of in both a qualitative as well as a quantitative way from the top down. It requires measurement, a way to objectively and reliably measure hand-hygiene compliance and performance. That’s why we developed the DebMed Group Monitoring System, or GMS, to provide an accurate and reliable 24/7 way to provide feedback.”
The culture in the organization must recognize that hand hygiene is expected, not just of staff but all visitors to a patient’s room. To do that requires the appropriate signage and cues both for staff and for casual visitors. “Patients should be educated and reminded of the important role that they play in their care,” comments Alper. “The tools that companies such as DebMed provide address all parts of the community. When we say hand hygiene is a habit for all, we mean patients, family, visitors, as well as healthcare workers.”
Greenville Hospital System, Greenville, South Carolina, is using the DebMed GMS for automated real-time monitoring and reporting of hand hygiene compliance through 3,500 soap and hand sanitizer dispensers across five hospital sites. The system has captured and reported on more than eight million hand hygiene events so far.
“Electronic monitoring is a critical element of our overall hand hygiene compliance program. The DebMed GMS was the only system of its kind that we felt fully met our needs. It is working so well that it’s difficult to imagine monitoring without it,” acknowledges Thomas W. Diller, M.D., Vice-President of Quality and Patient Safety.
The biggest issue has been getting people to believe the numbers. The compliance rate that’s coming out of the GMS system is lower than what they were seeing from direct observation. “In other words,” Diller admits, “they’re not doing as well as they thought they were and they don’t like that. And so from a cultural perspective, that has been a barrier that we’ve worked through and are going to have to overcome.”
One concern has been privacy. The DebMed GMS system does not measure individual performance; it measures a unit’s performance. “You can talk about Big Brother,” cautions Diller, “but we’re not measuring Susie Smith or Jim Jones, what their compliance rate is. The numbers are never used in terms of a punitive situation, they are used in a positive way by saying, ‘Here’s the unit’s numbers, the unit now needs to figure out how to improve that, we’re holding you all accountable for improvement.’ But an individual staff member or physician is not going to be punished in any way, shape or form because of this measurement system.”
At Greenville, the rates of infection have decreased in a statistically significant manner over a four-year time period, and the rate of clusters of outbreaks has also decreased significantly over that time period. Diller adds, “Of course, hand hygiene was one of many things that was done during that time period, We also did a lot of work on surgical-site infections, central-line infections, ventilator-associated pneumonia infections, etc., and collectively all of that work has led to a substantial decrease in infection rates. Hand hygiene is a core component of those programs.”
Once the culture of the organization is focused on hand hygiene, monitoring and measuring are keys to improvement. By analyzing the movement of people or items and their interactions, you can track potential contagion pathways to prevent the spread of infection.
One approach, pursued by Versus Technologies Inc., Traverse City, Michigan, is to monitor actual hand hygiene compliance events in real-time. Henry Tenarvitz, chief intellectual property officer at Versus Technologies, explains their history: “We’ve been selling real-time locating systems (RTLS) in the clinical environment since the mid-1990s, and in the case of hand hygiene, we use a one-second location change update so we can keep up with caregivers who stop briefly at a sanitizer dispenser to get some sanitizer and then are on their way into the room. We can capture that event.”
The accuracy of the system can be defined so you can tell if a caregiver is in a room or you can tell where in the room that person is—at the bed, the hygiene station, or the lavatory. “We focus on providing just the location accuracy that’s needed in order to be able to perform whatever automation the client wants to perform,” Tenarvitz notes. “In the case of gel-in and gel-out, it is typically to know that the caregiver is going into the room, or exiting the room, to know their compliance state when they’re going in or coming out.”
Versus can provide a retrofit generic tag that can be adhered to any existing dispenser. It’s good for recording usage, which is important—most facilities can’t track how much gel or sanitizer is dispensed at any given station. “And we also have an integrated device with our GLS sensory network built right into it,” Tenarvitz says.
How does Versus handle the “I only stopped by to say hello” problem? Tenarvitz recalls, “One of the things that we learned from the very beginning was that a nurse or a doctor just stopping at the threshold of a door and looking to see who’s in the room or saying something and then leaving is really different than entering the room. So we have a thing called a room-claim timer and the customer sets it so you have to be in the room for a certain time before we’ve said that you’ve moved to that location.”
And there are also timers on the dispensers themselves. According to Tenarvitz, “You set the timers for room claim, typically five seconds, and the time that you have to gel before you’re marked noncompliant is typically 15 seconds. The sanitize event has a duration and that’s typically 60 seconds.”
He adds, “A nurse demonstrated the real world application of this to me at Cedars Sinai. They took the recommended amount of gel from a dispenser and went into the first room—they were in there for six or seven seconds, they came out, did a second room, then a third room, then a fourth room. When they came out of the fourth room, they were still wiping the gel off their hands. The nurse said to me, ‘You know, according to the rules that you have set up, I was supposed to gel eight times—once on the way in and once on the way out of each of those rooms—and you saw that I claimed each of those rooms, but I couldn’t possibly have gelled eight times.’ So, we added to our product this duration, or the amount of time that a gel or sanitize event persists, and that’s typically sixty seconds.”
The average hospital spends about $7 million a year on hospital-associated infection costs. Medical experts agree that half of those hospital-acquired infections are preventable with proper hand hygiene. Any approach that can improve hand hygiene should be investigated. Technologies are being developed, hygiene products are available, and facilities are testing methods such as signage and readily available dispensers to increase compliance by caregivers, patients, visitors and staff. If we can cut the gap between 75 and 100 percent compliance in half, then hopefully it can reduce that hospital-acquired infection expense in patient suffering as well as financial loss.
Tom Inglesby is an author based in southern California who writes frequently about medical technologies and improvement strategies.