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POOR hand hygiene compliance by doctors compared with nurses has been the “elephant in the room” for too long in the battle against hospital-acquired infections, according to a leading infection control expert.
Dr John Ferguson, director of infection prevention and control at Hunter New England Health, was responding to research published today by the MJA reporting that medical staff consistently performed below the national threshold for hand hygiene compliance. (1)
Analysis of data from three cross-sectional datasets — Hand Hygiene Australia, and hand hygiene rates and Staphylococcus aureus bloodstream infection (SABSI) rates from the MyHospitals website — showed that nurses were compliant with hand hygiene protocols at a rate consistently above the national threshold, thus inflating the average national rate.
The researchers found that hand hygiene rates were not strongly associated with the overall rate of SABSI.
Professor Lindsay Grayson, director of Hand Hygiene Australia, strongly criticised the research, telling MJA InSight it did not acknowledge evidence of a drop in infection rates coinciding with the introduction of hand hygiene protocols.
“We have never claimed that the drop in hospital infection rates is due to the National Hand Hygiene Initiative and we acknowledge that we can’t directly attribute the decrease to it”, Professor Grayson said.
“But it is clear that a decrease [in infection rates] was observed after the introduction of hand hygiene protocols.”
Professor Grayson said the research methodology had not allowed for a “lag” between the introduction of hand hygiene measures and any subsequent decrease in infection rates.
However, Dr Ferguson said the research was “just what we needed”.
“Doctors have been the elephant in the room for far too long”, he told MJA InSight. “Doctors are very autonomous and they tend to be focused on individual patients. They are not seeing the system-level things that affect patient care on a population level. The individual physician is not in that mind space.
“The challenge is bringing the doctors to see that their actions matter and are critical to patient safety.”
Nurses were more compliant with hand hygiene protocols because they were “very good at lifting their game”, Dr Ferguson said.
“Doctors don’t listen or aren’t aware that it’s [hand hygiene] audit day, and they respond to authority very differently from nurses.”
Brett Holmes, NSW branch secretary of the Australian Nursing and Midwifery Federation, agreed, telling MJA InSight that nurses were “respectful of the rules”.
He also agreed with the MJA authors who recommended narrowing the focus of compliance protocols to the two most critical steps, before and after touching the patient.
The MJA authors wrote that a third of patient interaction hand hygiene opportunities recorded in their research involved the first of the WHO’s Five Moments for Hand Hygiene, which was before touching the patient. However, they found compliance for this was below the national threshold in 68% of the 82 public hospitals included in the research. (2)
“We must shift our focus to providing medical staff with immediate feedback and move to improving a single hand hygiene indication at a time, starting with before touching a patient”, they wrote.
Mr Holmes said the five actions per patient recommended by the WHO were problematic “when the pressure is on”.
“But if nurses can do it then doctors can as well.”
Dr John Quinn, executive director of surgical affairs for the Royal Australasian College of Surgeons, acknowledged that doctors were “not performing as well as we should” when it came to hand hygiene protocols.
“It’s not a conscious thing”, he told MJA InSight. “It’s about time and habit. Facilities for hand hygiene also vary greatly from hospital to hospital. If [the facilities] are at the end of every patient’s bed, then they tend to be used.”
Dr Ferguson agreed with the MJA researchers that the use of unadjusted average hand hygiene compliance rates as a measure of hospital performance in terms of SABSI rates was misleading and concealed the fact that most hospitals and medical staff were performing below average.
He said compliance was being overestimated because of the observer effect.
“That’s not a bad thing when you’re talking about quality improvement because people comply more when they know they’re being watched but it’s not good in terms of accurately measuring performance. We’re focusing too much on hand hygiene as a performance measure and we’re not facilitating an improved model for action.”
1. MJA 2014; Online 28 April
2. WHO 2014: Five moments for hand hygiene
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Thanks, Ian – that is my point exactly. If I am told that I am sloppy with patients with wounds, or who have been in hospital before, or who need a detailed examination, then I will take notice and try to improve. If I am told that I have failed the ”five moments” when I approach a patient just to check the history but don’t touch them, I will be less concerned. It isn’t a matter of ”universal precautions”. If you don’t touch the person and they don’t cough or sneeze, you can’t transmit anything between you, in either direction.
This is where the problem lies, because if you are treating every patient as if he may have E. coli or VRE on his hand, then every time you touch the patient, your hand needs to be disinfected. Another option is to double glove, discarding the outer pair of gloves each time you pause the examination and reach for the pen or keyboard. Every doorknob which the patient has touched, every chair, and every hard surface such as a desk top, needs to be disinfected.
Try this simple thought experiment: at a hospital function, you have a drink in your left hand. The chairman of the AIDS Council greets you, offering you a firm handshake and a home-made canape. Do you (A) Refuse his handshake and food. (B) Shake his hand, decline the food and sneak off to the bathroom to wash your hand. (C) Shake his hand, then sanitise your hand with an alcohol prep, or wash your hand in front of him, then accept the canape, or (D) greet him warmly, shake his hand, and enjoy his cooking, safe in the knowledge that you do not get AIDS from a handshake.You cannot catch AIDS from examining someone’s hand, nor can you catch AIDS from listening to his chest with a stethoscope, so washing your stethoscope or hands does not decrease a non-existent risk. However, you can catch SARS from touching a hand, or the lift button that they have touched, and a barrier precaution would be necessary, i.e. always wearing gloves. If there is any bodily fluid contact, then universal precautions i.e. dressing as one would in an operating theatre, are necessary. That includes when taking a history from a patient with a cough/sneeze.
Perhaps some of us are at cross purposes in the above thread. I am considering the patient who turns up in my consulting rooms, or Hospital clinic, as a specialist hand surgeon. Almost all patients who do so have intact skin, and have no more cross infection risk than shaking the hand of any stranger to whom one is introduced in the street.
To access the clinic, the patient presses the button on the lift and opens a doorknob. He fills in demographic data with a borrowed pen, gives his Medicare card to the receptionist, and takes a seat in the waiting room, where he reads a magazine.
When you greet a patient, you introduce yourself, and shake the patient’s (uninjured) hand. You also greet relatives who accompany the patient.
The patient pulls up a chair and sits down. He hands you the referring doctor’s letter, which you read and place on your desk.
You then take a history making contemporaneous notes. You then examine the patient, again making contemporaneous notes. I do not know how other people do it, but I am not capable of remembering all the angles/ movements/ grip strengths/ neurological data, etc of a complex hand examination, without writing it down as I go.
Andrew misunderstands my point. It is not to avoid improving compliance, but to gain compliance by appealing to reasoning rather than obedience. We are taught as a profession to look for evidence and make sensible decisions, not just to follow orders. If I put on a pair of gloves before touching intact skin, then, at the end of the encounter, remove the gloves and wash or alcohol rub my hands, have I taken precautions or have I failed to meet the ”five moments”? Tell me how much transmission I could avoid by greater compliance, and you may have defeated my excuses. Tell me to do it ”just because”, and you haven’t.
Stratification by risk is asking for it – remember the logic of universal precautions in laboratories and elsewhere – “it is the one not labelled as infectious that will get you”
We doctors are crap at handwashing even when we make it really simple. We will be even worse ( or have more excuses ) if we make it complex
I attribute a lot of it to testosterone encephalopathy, which seems to affect many of the leading offenders – ” I am a powerful middle aged male and no bloody nurse/patient / Lab-ID nerd is going to tell me what to do”
We have to get it right, as within the next decade or so we are going to be dealing with untreatable infections and infectious death on the job will once again be a real occupational risk for doctors, as it was for millennia until relatively recently. We might start to take it seriously when we start doing the dying.
It is worth remembering that the big falls in puerperal and postoperative infectious mortality had nothing to do with antibiotics – they occurred well before any were available and were essentially due to an understanding of transmission and attention to hand hygeine and asepsis.
We do have to make it easy – our unit has alc/chlorhex on end of every bed, with 2 or 3 others only three paces away. Everywhere. Makes it possible to have “no excuses” policy.
Culture is important too – I knew that we were finally making progress when one of our mothers gave me a bollocking for a slip in procedure. Wasn’t happy at one level, but was very happy at another.
Sorry Sue Ieraci
When I’ve finished with a patient I have a need to disinfect my hands which is like an itch. And URTIS – which often precipitate asthma – make me itchier than most, because I think that cold and flu are probably the commonest transmissible diseases in the DEM.
But I’m getting a bit tired of the blame game. Give us the facilities, including sinks in EACH patient care area, disinfectant wipes for keyboards and stethoscopes – I’m with Dr Cochrane on that one (in spite of advice from a surprised medical registrar that I will perish the rubber!) And for goodness sake, a few rooms with ensuites for the use of patients with gastroenteritis.
I think Sue Ieraci is correct. Health policy, such as hand hygiene policy, is often presented as dictatorial decree without rationale or evidence and doctors as a group don’t respond well to initiatives presented in this manner. Certainly, any doctor can independently research the evidence base for such policy but then, policy makers also need to consider the target clinicians for their policy and implement it accordingly to achieve optimal compliance.
I am a physician and I am committed to practising hand hygiene before and after each patient but I don’t pretend that I’m perfect. Sometimes I do forget. Also, it’s important to acknowledge that there are challenges to maintaining hand hygiene and patient privacy at the same time, particularly if there is no means within curtained cubicles and you are attending the patient solo.
However, the main point of my comment is to draw attention to my stethoscope – no person or policy has ever recommended that I sanitise that between patients. Nevertheless, I attempt to do it regardless of policy recommendations. When we are audited on hand hygiene, there is no data recorded on what happens to the stethoscopes (and other medical tools). It seems ridiculous to focus on clinician hands only and completely ignore the stethoscopes (and other tools of the trade). Inconsistencies such as this lead to an exasperated and despondent clinician response towards the policy.
And another factor – do we stratify hand-washing performance according to the infectious risk of the patient encounter? Doctors respond better to data that reflect sensible practice than they do to blanket rules. Let’s see the data on hand-washing and glove use for examining patients with wounds or infections as opposed to – say – asthma. If we are shown to be poor at the practice for the patients where the impact is greatest, more people will be motivated to change their practice, I suspect.
In over thirty years of hospital practice, I have seen hand hygiene practices change dramatically – but so has the rate of resistent organisms. We feel we are adapting, but perhaps not rapidly enough. In my view, the best way to appeal to doctors is to provide the evidence – not just gross compliance data, but which of the five ”moments” are most crucial, and which have best compliance. It is disingenuous to think that each of the five ”moments” have equal impact. Tackle the most important first, show the impact, and then continue to the others. Report each of the five ”moments” by risk and compliance, separately.
The reasons that doctors don’t clean their hands have been outlined in the comments to date.
1) They don’t believe they need eg “Why do I need to clean my “healing hands?” This is consistant with not believing in the germ theory of infection.
2) They don’t understand the reasons for the way hand hygiene is taught – eg I don’t need to clean my hands after touching a wrist ganglion”
3) They don’t believe it is a major contributor to HAIs eg “HAIs are due to overuse of antibiotics” – an of course overuse of antibiotics is a significant problem but there are systematic and significant efforts being put into (at least the public hospital sector) to improve antibiotic prescribing.
The need for good hand hygiene has been discussed in the public arena for some years now and ignorance can’t be claimed as an excuse.
Not cleaning our hands before and after patient contact is sending a very strong message to the patients we treat (and their families and carers) and our senior and junior colleagues that we don’t care about this aspect of patient safety.
Really?! I can’t believe what I’m reading. ‘I return to a shared work area with keyboards and handsets which are never cleaned and wonder why I bother?’ You bother because that’s how you stop the organisms from these telephones and keyboards (including your own mobile phone) from transferring to your patients – hand hygiene ‘before touching a patient’ EVERY SINGLE TIME. ‘If I was treating patients with SARS, I would most certainly be disinfecting my hands extremely regularly, as well as wearing gloves, gown and a full face shield. ‘ – well, you don’t know you’re treating a patient with SARS until well after you’ve done so, and maybe by then you’re the sick one, if not your next patient. ‘if I am only examining your wrist ganglion I do not need to disinfect myself before I touch my pen and my clinical notes’ – oh yes you do! That’s the patient who last month holidayed in one of the many overseas countries where multiresistant organism colonisation is rife, and you’ve just picked up that organism from their hand and will put it onto your pen, then you’ll put it onto your next patient and their wound will get infected with an ESBL-producing E. coli or some sort, and effective treatment will be very late because those types of infection don’t happen here. Worse, it’ll be VRE.
Yes, we must wash EVERY SINGLE TIME. NOTHING LESS IS ACCEPTABLE.
Why is it so really really hard to get really really intelligent people to do really really simple things?
It’s simple, and it’s smart.
Witnessing not one health professional performing hand hygiene before examining our child in a tertiary institution was a wake-up call. As uncomfortable as it may be for all involved I think next time we will remind care-givers to do so if they have not performed hand hygiene in front of our eyes – and probably that is what is required (and lacking) to make us doctors change our ways – Scrutiny.
Mr Hargreaves is incorrect. The 5 moment model stiputaltes that you should complete hand hygiene, once only,direclty before touching a patient preferably at their bedside, and then no further hand hygiene is required unless he moves to doing an invasive procedure (such as cannualtion) or if he were to touch bodily fluids. or unitl he leaves, not again just before ” examing “a patient or everytime somehting is touched. When it comes to hand hygiene compliance, Doctors have it very easy compared to Nurses who do many complex procedures and touch mutliple bodily fluid drains etc. Doctors who mainly have to complete moment one and four, before and after touching a patient should be up in the 90 % mark. Yet still even in this forum Doctors are asking for proof of why they need to clean their hands as often as they should when WHO have presented the best data they have on why 5 moments is the best modelat this point in time to assist in the prevention of HAI . I take offense that others follow policy but Dr’s dont’ because they use commonsense ? What does that say about the thousands of staff that do ? That they are sheep and only Dr’s can decide when and when they will not follow policy that is desgned to reduce harm. I liken it to wearing a seatbelt, I have been driving for 30 years and never had an accident or really any reason to believe that a seatbelt is needed to keep me safe, yet everytime I put it on and I make sure that everyone in the car does as well. Along with drving safely it is the best I can do to keep me and others safe but it is not failsafe . The same goes for hand hygiene.
As Princess Diana movingly demonstrated, it is perfectly safe to touch the hand of an AIDS patient, then another AIDS patient, without risk to oneself or the patients.
There are those who would suggest that when I greet a patient I should wash my hands before I shake his hand, wash my hands before I shake his father’s hand, and then wash my hands again before I examine the patient. That is certainly what the WHO regulations state, washing hands before and after patient contact.
If I was treating patients with SARS, I would most certainly be disinfecting my hands extremely regularly, as well as wearing gloves, gown and a full face shield. My hygiene levels would be what they are in the operating theatre. However, if I am only examining your wrist ganglion I do not need to disinfect myself before I touch my pen and my clinical notes, nor to disinfect myself after touching my computer keyboard to show you a photograph on a website, during the clinical examination. You will not be issued with a backless gown on arrival in my rooms, nor made to sit on a plastic-sheet covered chair, with disposable drapes on the examination table.
It produces a work-to-rule scenario of Arthur Scargill proportions, if I am required to be making detailed contemporaneous notes (without using an eco-unfriendly disposable pen as I do in the operating theatre) during the examination, and maintaining a hygiene barrier while having empathetic human contact with my patient.
I suspect the main reason doctors do not comply with prescriptive rules is that we use common sense and professional judgement, not a policy manual treated as holy writ.
Dr Quinn is right about facilities -if there is a basin in the room I like to wash my hands as I introduce myself/apologise for the wait/ensure I have the right patient and right chart with me. The ratio of handbasins to beds is appalling in most emergency departments, and its not uncommon for the only basin in an area to be within a cubicle, making it awkward if privacy curtains are drawn. Washing as I come in reassures patients who have read about handwashing statistics, particularly those have received advice to ask us about it!
But there is another, related issue, documented in this journal a number of times but particularly see Coiera et al https://www.mja.com.au/journal/2002/176/9/communication-loads-clinical-staff-emergency-department. The further I must walk to a hand basin, the more likely it is that I shall be interupted en route, and if there are several interuptions I might lose my focus. Yes, I know one can use alcohol based disinfectants, but if I’ve just been examining a gastroenteritis or looking down the throat of a sneezy child, I really want to actually wash my hands.
Meanwhile, I return to a shared work area with keyboards and handsets which are never cleaned and wonder why I bother? These are the worst fomites in the hospital! I do disinfect my work area, but I can’t do that for every area I visit and its clear from the state of those I do clean tht this isn’t routinely done.
The two previous comments underline the problem with getting docotors to wash their hands which is primarily attitudinal. Many doctors do not want to accept simple rules can impact disease management more than their clinical decision making. Good hand hygiene has been linked to decrease infectious disease better than any other measure however health professional still want to disagree and trivialise the need for washing hands. While the miss-use of antibiotics certainly has an impact that is only after the infection has been developed the point of good hand hygiene is to prevent infections not treat them.
Hospital acquired infections are due to the over use of antibiotics that is rife in our hospitals – not to poor hand hygiene. The WHO estimates that 50% of antibiotics that are prescribed are unnecessary. Washing hands is not going to get rid of this problem and this is why there is no correlation between hand washing regimes and infection rates in hospitals.
Why should Doctors sanitize their ‘ HEALING HAND ‘ ? ? ? ! ! !