Interview with Rita McCormick, RN, CIC, Senior Infection Control Practitioner, University of Wisconsin Hospital & Clinics Authority
Peck: Stepping back a little from the regulatory aspect of things and more toward the practical, in terms of judging a product, wouldn't a staff know that a product is not quite right for them, even without the data if, after using it awhile, their hands are starting to get rough and scaly?
McCormick: When you look at the contents of the CDC's hand hygiene guideline, it is very clear that the product you purchase for your facility should meet user acceptability criteria, and costs should not be the major component. I am very disappointed when I hear people say, "Well, I was told we had to buy such and such because that is what is on our contract."
Peck: Isn't it possible to make a cost case that by buying just the cheap products, you're going to be spending more down the road to remedy the results, whereas the more expensive product might reduce future costs?
McCormick: It's possible. But I'd say first of all, if staff doesn't like it, they will not use it, and you will fall short in preventing infections. If they don't use it and think they have to resort to using soap and water, we know from studies how miserably we have failed in encouraging optimal compliance with the use of soap and water. If done properly, handwashing can be effective, but we have not been successful in achieving optimal compliance.
Peck: Haven't studies shown LTC staff handwashing compliance rates of as little as 20%?
McCormick: If you review compliance rate data over the past 25 to 30 years, you'll see periods when compliance rates increase, but the increase wasn't sustained, and that is the problem. Essentially you find a Hawthorne effect: Just the act of paying attention improves things for a while, but the effect wears off. If you could sustain a Hawthorne effect for an indefinite period of time, you would be in good shape, but we can't seem to do it. We get busy doing other things, nobody champions the cause, and pretty soon, even though you had a nice boost in compliance, you slide back into noncompliance.
Peck: Would it help if LTC purchasers would buy products that are more acceptable to the staff, perhaps such that they would be more inclined to use them?
McCormick: Yes, I think it would, and I think success might also be predicated on the people who champion the cause-are they seen as highly credible, well liked, charismatic? If you can pick such people, you'll do better.
Another aspect that is often overlooked is the powerful impact of a good role model. Physicians and nursing managers who are extremely vigilant about setting a good example and verbally setting the same expectation for all workers are often amazed at the "trickle-down" effect on compliance.
Peck: Is there another approach to compliance that perhaps might be used on a regular basis?
McCormick: One study recently looked at monitoring compliance at the patient level, giving patients the power and the license to say to the staff person, "Have you washed your hands or have you used alcohol gel?" Maryanne McGuckin of the University of Pennsylvania has done a number of studies in which patients were taught to ask healthcare providers to wash their hands. The results showed significant improvement in performance. One variation of one of these studies was to give patients a cute little fuzzy weeble-looking thing that had a tag on it that said, "Did you wash your hands?" You could give them to patients to stick on their gowns and, if they did not want to ask you verbally, they could just point to the little weeble. The results provided tangible evidence that you can empower patients.
Interestingly, Professor McGuckin found in subsequent studies that approximately only 30% of patients were willing to ask the physician the handwashing question, but they would readily ask the nurse at a rate of above 70%. And yet physicians are prime offenders. Also, this approach would not work in an ICU where you have patients who cannot be their own advocates. As a result of these findings, researchers are pursuing methods of automating audits of hand hygiene compliance. The results of these audits will provide good information about and improvement in compliance over time. Other research has shown that it is possible to achieve positive change by providing feedback to workers about their performance. Most workers want to do a good job and are willing to make the necessary changes when provided with accurate information on the need for improvement.
Peck: One thing that seems to get people's attention these days is legal action. Do you know of any liability suits that have been brought in cases where failure to properly handwash led to a serious or fatal infection?
McCormick: I'm aware of a case in which two patients shared a room; one had a staph infection, and the other observed that the employees did not wash their hands well before they attended to him. Unfortunately, he developed a staph infection, too, and sued the provider. He won his case. Interestingly, the strain of staph that the second person had was different from that of the first patient, and it is possible that the source of infection for the second patient was his own skin flora. The jury did not consider that in their verdict. You just never know what a jury is going to do.
Peck: Staff these days are wearing gloves all the time to protect against HIV and other bloodborne pathogens, and sometimes think that by doing so, they're covered and don't have to worry about handwashing. Your comments on that?