Thursday, March 11, 2010

Straight talk about hand washing

Vanderbilt University Medical Center (VUMC) recently reported a hand washing compliance rate of 78%, far better than has been reported elsewhere. Why? Well, as early as 35 years ago I remember folks there like William Schaffner harping on it. And nowadays they're addressing it as a system problem. The approach focuses on aggregate compliance rather than a punitive approach against individuals:

“Hand hygiene remains the single most important clinical safety practice that we can improve upon,” Kaiser said. “Now, to the credit of our overall health system, it's finally agreed that the only way to have success is to have observers routinely counting and reporting adherence with the standards.”

Good hand washing compliance should be the low hanging fruit in patient safety, yet the goal remains elusive. Kaiser is interim chair of Medicine and Chief of Staff of the hospital. He's an ID doc who's treated patients, taught and researched the field for nearly 30 years, and has written numerous articles and textbook chapters on prevention of infection in hospitalized patients. Recently his interests have morphed into administrative, safety and quality aspects of hospital medicine.

The systems approach at VUH involves over 100 monitors logging up to 2000 observations per month. Though somewhat artificial it's robust and perhaps the best that can be implemented with reasonable resource use:

“If you're not touching the patient and you're not touching anything in the patient's environment, there's nothing in the germ theory of disease that would require you to have washed your hands, so in that respect any rule for observation is going to be somewhat artificial,” said Kaiser, who is a founding member and past president of the Society for Healthcare Epidemiology of America, a health care safety group.

“But the only alternative to observation and reporting would be to ensure adherence directly by following every provider into every room.”

The importance of hand washing has been a no-brainer for a long time, so why have hand washing rates been so low? Its' not a careless disregard for the patient as some have suggested:

“We all believe the germ theory these days,” Kaiser added, “but in many patient care contexts, we still have trouble getting providers to predictably wash their hands. I think that has to do with there being no immediate complications for the patient from non-adherence. And it's to be acknowledged that in most cases there won't be a complication — most times it doesn't mean anything.

“However, in the event that a harmful pathogen is transmitted to a patient, the results can lead to unexpected morbidity and even mortality,” Kaiser said.

Doctors are inherently very vigilant about things that have direct, immediate consequences. Hand washing is not one of them. A new way of thinking is needed.

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