As hospitals around the country stress hand washing as a means of reducing infection, a suburban Philadelphia medical center has kicked it up a notch. In a new twist to the existing hand hygiene campaign at Abington Memorial Hospital, poor hand-washing habits now could cost staff their jobs. Those observed not washing their hands or using hand sanitizer when entering or leaving patient rooms will be handed index cards noting their noncompliance.
After three infractions, offenders will receive a letter stating that their reappointment—which is required every two years to keep their jobs—is conditional. Staff members observed adhering to protocol, however, may be given index cards making them eligible for a prize raffle. “They’re really serious about [hand hygiene],” said Bob Spivak, RPh, a clinical staff pharmacist who has worked at the hospital for about 35 years. “They want everyone to comply.” About two years ago, the hospital started a program in which employees serving as “spies” observed and reported how often doctors and nurses washed their hands or “gelled” (used hand sanitizer dispensers posted outside each patient room) when entering and leaving patient rooms.
Initial surveys showed that the compliance rate was 31%. Soon after, the hospital began a major push to increase hand washing, including lecturing offenders and promoting hand hygiene through screensaver messages on every computer in the hospital. As a result, the percentage of staff washing hands increased from 31% in December 2007 to 88% in September 2009. It has since leveled off at about 80%, according to a recent Philadelphia Inquirer article, although the aim of the three-card infraction program is to get hospital staff closer to 100%. Spies conduct between 800 and 1,400 observations each month.
A Downward Spiral To make the message more personal, Abington’s chief of staff, John J. Kelly, MD, tells the story of patient Catherine “Pat” Zakrzewski, who had knee replacement surgeries at the hospital four years ago. One of her kneecaps later split, requiring her to return to the hospital for surgery. While an inpatient, she acquired methicillin-resistant Staphylococcus aureus (MRSA) infection, which led to a downward spiral including removal of her new knee, amputation of a leg and—after a combined 20 surgeries and hospitalizations—her death last April at age 77, the Inquirer reports.
“Almost certainly,” Dr. Kelly told the Inquirer, the infection was carried to her bedside “on the hands of someone in the hospital.” Mr. Spivak said the hospital has tried several means of increasing hand hygiene com pliance, including a “Gel in, gel out” campaign to encourage use of sanitizers, screensaver-based messages and even a promise last year to award every employee a $300 bonus if the hospital met its hand hygiene goal for six months straight. It did, and Mr. Spivak and others received their bonuses. Hand hygiene rates are announced to employees each month.
“Believe me, it’s ingrained in my head,” Mr. Spivak said. He said nurses and physicians who enter and leave patient rooms frequently are the most affected. As for the pharmacy, technicians used to go into patient rooms on a regular basis to exchange medications, but automated drug dispensing machines located on patient floors mean that happens much less often. Still, there are clinical coordinators who make rounds and are expected to observe hand-washing practices. Occasionally, Mr. Spivak or colleagues may need to mix medications like an epinephrine drip on an inpatient unit and run it into the room.
Even with these stat orders, the pharmacists need to remember to stop and use gel on their way into patient rooms, he said. ID Pharmacist Embraces ‘Observer’ Approach Robert C. Owens Jr., PharmD, co-director of the Antimicrobial Stewardship Program at Maine Medical Center in Portland, said hospitals nationwide are looking at a number of strategies to increase hand-washing compliance. At his own hospital, for example, independent observers planted in the hospital report those with poor hand hygiene to their department heads, who later pull the staff members aside for conversations.
The catch is getting staff to be aware of what they did immediately, instead of approaching them days later when they may have forgotten the surrounding circumstances. Dr. Owens said he is impressed by Abington’s almost 90% rate of compliance with hand washing. About 34 studies, he noted, conducted over the past 20 years have shown that the median hand hygiene rate nationally is only about 44%. “Yes, it’s that bad, and it’s that widespread a problem,” he said.
As for whether other hospitals should take similar measures, “I don’t think there is a right way or a wrong way to [promote hand hygiene], there are just right ways,” he said. “It’s all good for the patients.” As pharmacy is moving toward a more decentralized profession, with pharmacists or pharmacy residents rounding with medical teams or verifying medication orders in patients’ rooms, Dr. Owens noted, hand hygiene policies will more likely affect them. —Karen Blum.