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Hand Hygiene

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Tom Talbot

on 8 August 2013

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Transcript of Hand Hygiene

Tom Talbot, MD MPH
Associate Professor of Medicine
and Preventive Medicine
Vanderbilt University School of Medicine
Chief Hospital Epidemiologist
Vanderbilt University Medical Center

Use of a Comprehensive Program to Improve Hand Hygiene Compliance and Instill a Culture of Safety
Improve a safety practice
Reduce healthcare-acquired infections in patients and healthcare workers
Make the practice habitual/reflexive
Create a culture of shared accountability
Erode traditional “silos” of practice
Create a culture where it’s expected to remind
others to “do the right thing”
Why Focus on Hand Hygiene?
Delay between defect and adverse outcome
Unlike transfusion of mismatched blood, e.g.
Impossible to trace specific event as single cause of infection
Many other factors upon which to lay blame
Limitations of the measurement
It’s difficult to remind peers
You have to alter basic behaviors
Challenges with Changing
Hand Hygiene Practices
Claudette Fergus
Nancye Feistritzer
Gerald Hickson

Acknowledgements
June 2009
“Show me the evidence that this actually improves patient outcomes.”
Perception that hand hygiene is “fad of the moment” vs. a foundational infrastructure program for HAI prevention and just culture programs
Hawthorne effect/biased towards day shift
Sustainability of our gains incl. preventing observer and leader fatigue
iPod data entry application
Unit-based embedded observer program
"Sputtering units"
Moving Forward: Challenges
http://www.youngallies.com/fever/
Cork DP et al Amer Surgeon 2011,77:123+
http://www.valuesystemdesign.com/semmelweis.htm
The Story of
Edna Wilson

Lessons Learned Along the Way
Smart People Create Not-So-Smart Reasons for Poor Practices
Minor Issues Can Become Major If Not Addressed
Not All Practice Areas Are Alike
Face-to-Face Discussion Trumps Email Every Time
Know in Advance On Which Swords You Are Willing to Fall
Find Advocates;
Use Champions;
Convince Skeptics
http://www.thefuntheory.com/
“Our patients are all healthy and won’t come into clinic if they are sick.”
“Use of the alcohol foam is causing our MRSA outbreak.”
“I see 18 patients each clinic. You really expect me to wash my hands for every single patient? Multiple times??!!”
Favorite Excuses for
Not Performing Hand Hygiene
Gawande A NEJM 2004;350:1283+
What % of General Public Wash Their Hands After Using Restroom?
Ignoring a complaint can cause opposition to improvement
The "Slick Floor" example
Inpatient vs. outpatient
Open wards vs. single patient rooms
Procedural areas
OR suites
Sink in room
“Why aren’t we pushing patients to wash their hands? Why is all the blame put on doctors? They go out and touch dirty doorknobs at Wal-Mart. Who knows what’s on their hands!!”
“I am so busy that you need to have a nurse follow our team on rounds, holding a foam dispenser, and squirt foam out into each of our hands as we enter and leave the rooms.”
Incr. Observer Pool
Professional Reminders
Shared Ownership Observation Program
MCMB Endorsed
Measurement Guidelines
Marketing Campaign
Awareness Letters
Monthly Scorecards
Unit-Based Initiatives
Added as Quality Goal for Allocation Rebate/Chairman Goals
Fries J et al ICHE 2012;33:689+
Polgreen PM et al ICHE 2010;31:1294+
Making a Better Hand Hygiene Observation
Gormley NJ et al Crit Care Med 2012,40:290+
“I declare before God and the world that you are a murderer and the ‘History of Childbed Fever’ would not be unjust to you if it memorialized you as a medical Nero.”
Best M, Neuhauser D. Qual Saf Health Care 2004;13:233+
“You, Herr Professor, have been a partner in this massacre.”
http://www.youngallies.com/fever/
http://www.valuesystemdesign.com/semmelweis.htm
Noakes TD et al Epidemiol Infect 2008;136:1-9
Mandatory use of chloride of lime
Key event: Death of pathologist Jakob Kolletschka by scalpel injury sustained during autopsy
Routh CHF. Lancet 1848; ii:642-3
Died from sepsis related to autopsy injury
Delay of 14 years to publish findings
Tracked movement of HCP with wireless “motes”
Examined how/when/where to observe
60 min period on MICU:
0.5-1.7% of all opportunities captured
If use smaller intervals (1-15 mins) and move location:
Samples more unique people
Best estimate of “true” compliance
16 peer-reviewed studies noting significant association with reduced HAIs
Gordon SC JAMA 2012;307:1591+
Longtin Y Arch Intern Med 2012
37% would not consent to wearing a badge to remind pts to ask about hand hygiene
27% felt having patients ask about hand hygiene would be humiliating
What about engaging the patient?
Patients as Partners
Large academic medical center, Nashville, TN
Adult hospital
6 ICUs (incl burn, trauma), transplant program
Free-standing pediatric hospital
Serves middle TN extending into S. KY, N. AL
Extensive outpatient network
What About Automated Monitoring?
e.g. RFID in name badge
Active/passive sensors

PROs: Prolific amount of data; provider-specific data
CONs: Lose real-time correction; ±expensive
Addressing non-compliance by identifying specific persons
Assumes issue is due to limited few
? Within spirit of just culture
All persons equally under surveillance?
If responds unprofessionally to reminder = different issue
Taking Names
All HH Observers
HH Leadership Team
All VUMC faculty and staff
Full transcript