Giving a Hand to Best Hygiene Practices

“Building hand-hygiene compliance takes a multimodal approach. The World Health Organization (WHO) details elements of the approach, including system change (ensuring alcohol-based hand rub and soap and water are readily accessible), training and education, observation and feedback, reminders, and building a safety culture.” 

She continued, “Choosing quality hand-hygiene products that can support high levels of compliance in healthcare facilities and making these products accessible and visible to healthcare workers is likely the most critical element of a hand-hygiene program.” 

Jaimee Rosenthal, director of U.S. Healthcare Markets at GOJO, added, “An important part of any hospital infection prevention program is healthcare worker hand hygiene. As facilities on-board new staff and get back to basics with everyone, refocusing on the importance of good hand hygiene (covering when to use, how much, and technique) is an easy way to kick-start your safety and quality focus.” 

In agreement is Robert Lee, founder/CEO/senior biologist at MD-Medical Data, Quality & Safety Advisors, who pointed out, “In order to ensure that you not only meet but exceed established hygiene protocols, you have to first understand what those protocols and practices are. Not all hospitals or healthcare facilities are created equal with respect to protocols and practices.  Most nursing and medical schools also teach very little hygiene compliance. Both the CDC and WHO put out minimal compliance guidelines as ‘best practice.’ We have to be better than that and be ‘evidenced based.’” 

Hygiene-healthy environments 

Looking to hygiene practices in healthcare environments, Linda Lee, MBA, CIC, chief medical affairs & science officer at UV Angel, said, “Good hygiene is not just cleaning the room, it's not just what we've typically thought about in environmental services, but it's multimodal. It involves many things, and the air is often overlooked as a pathway of transmission. We should treat the air with the same diligence that we treat surfaces. By focusing on the air and how it interacts with these environments, and how can we provide a safer environment by treating the air.” 

According to Lee, the air within a healthcare environment is often overlooked, which can lead to accountability issues and airborne transmission of disease if not properly addressed. 

“I believe that one of the things that healthcare workers can ask in particular is ‘what are we doing for the air?’ Many infection preventionists, which I am, often focus on hands and whether we’ve wiped down surfaces, but we have lots of evidence that airborne transmission occurs. Yet, many healthcare workers don’t necessarily know what is being done for the air in the patient room, in their break rooms, in the areas where they congregate. Where staff often meet and interact, where they are dealing with people who are sick, where they're dealing with coworkers who may come to work with a cold, so asking those questions about ‘what is the facility doing to maintain accountability associated with the air?’” 

She continued, “We're constantly looking at new ways of cleaning surfaces or new ways to do hand hygiene or being sure that we have enough of these products to provide a safe environment. But if I ask most people in the hospital what they do for air quality they couldn't tell me. They might say ‘we're compliant with the regulation’ or ‘we provide good air because the facility said so,’ but do they really know what is going on with the air? How the air interacts with these other modalities of protecting patients and protecting coworkers within the patient care environment and, quite frankly, holding everyone accountable for the safest possible environment.” 

Awareness and accountability 

As with many factors that contribute to infection prevention, there is no one easy answer to the question of the best way to maintain hygiene accountability. Among the most noted and quoted replies from industry professionals are not only the awareness and education of hygiene practices, but also the verification by managers that any required compliance has been met. 

Nancy Moureau, PhD, RN, CRNI, CPUI, VA-BC, is CEO at PICC Excellence, Inc., and also a research and educational consultant for Parker Laboratories. She said, “Accountability for hygiene and safety for patients and healthcare workers revolves around educators and managers monitoring activities for compliance with policies. With the high volume of patients and procedures, the number of tasks can be overwhelming and lead to shortcuts, use of whatever supplies are within reach, and clinical judgment fatigue. Constant reminders through multimodal education are necessary to maintain high-level accountability and awareness of safety practices.” 

She continued, “But more than just education, someone needs to be watching. Just like with homework completed in grade school, if the teacher does not look at the work or grade the material, the student becomes less and less interested in performing at a high-level. While that is a simplified example, clinicians often need to be motivated by who is looking at their performance. Management performing walking-rounds of work areas provide that level of accountability needed to maintain good performance and accountability for the best practices.” 

Addressing best practices of accountability, GOJO’s DiGiorgio added, “The ideal would be to have an open, transparent, non-punitive environment where staff feel comfortable speaking up to one another if hand hygiene is not performed. When you’ve progressed to the point with your efforts where a nurse can stop a surgeon and remind him or her that they need to perform hand hygiene, it is truly a testament to what you’ve built with your program. It just takes a lot of work and is part of the ongoing multimodal strategy for improving compliance.” 

MD-Medical Data’s Lee, pointed out, “Infection prevention is not just about the patient. It is about staff safety, too. Creating accountability through compliance audits has been done typically through the ‘secret shopper’ methodology. Unfortunately, this method is very limited in scope, accuracy, subjectivity, and is relatively ineffective. The current evidence-based methodology is the use of technology that allows for 24/7 data collection.” 

He advised, “Be careful here, for there are a number of technologies on the market that advertise hygiene compliance. You need to understand what you want to measure. Some technologies only measure entry/exit at the doorway of the patient’s room. Some will measure patient contact. Some will measure various contact with patient environment, like workstations, keyboards, bathrooms, etc. The CDC says, ‘If you are measuring entry/exit methodology, you are measuring the wrong thing.’ So, it is important to select a technology that matches your safety protocols and workflow.” 

More education, less HAIs 

As hospitals and healthcare facilities look to meet established protocols for best hygiene practices, infection preventionists often look beyond the minimum requirements to ensure a higher level of hygiene is achieved whenever possible in order to prevent additional HAIs. 

PICC Excellence’s Moureau asserted, “Peripheral and central venous access devices are one of the biggest contributors to bloodstream infections. Many clinicians feel it is necessary to use more application of sterile insertion procedures. Unfortunately, observation shows us that even the most basic procedures have frequent contamination, that hand-hygiene practices are inconsistent, and that there is a need to emphasize basic aseptic non-touch technique practices for all procedures.” 

She continued, “One novel idea is using a sterile barrier between the skin and the gel and transducer, which reduces both infection risk and the level of disinfection needed for the ultrasound transducer. Another is having a standardized and complete IV start kit or central line insertion kit that clinicians can grab and use at a moment’s notice.” 

Reiterating the importance of education, she added, “Again, we are back to education as a key element to reducing infections and providing the necessary information to help clinicians function with safe practices for patients. More time should be spent teaching at the bedside, reinforcing the basic skills of asepsis, cleaning tabletop surfaces, preparing supplies, and disinfecting intravenous access ports prior to connection of an infusion. Integrating ultrasound and more technical devices into our procedures also requires education specific to the low-level and high-level disinfecting practices necessary to avoid contamination during insertion of needles. Every clinician should take responsibility for education, teaching others, reading the research and recommendations, and helping to reinforce best practices every day.” 

Suggesting healthcare professionals think outside the box, UV Angel’s Lee opined, “I absolutely think more can be done, I think looking at pathways of transmission and thinking outside the box. If we've always done something in a particular way and people are still getting sick, it is essential to think of alternative ways of transmission. Thinking beyond ‘we need to do more terminal cleaning,’ or ‘we need to step up routine cleaning,’ or ‘workers have to wash their hands more,’ but really consider the interplay between the air and people in the environment. The air may be creating pathways of transmission between surfaces, patients and staff. There is strong evidence that simple toilet flushing puts pathogens into the air, that land somewhere; on clothing, handrails, and surfaces in patients’ rooms.” 

GOJO’s DiGiorgio added, “While some issues cannot be solved immediately, returning to basic infection prevention measures can be initiated even at a local level. Unit-based managers are uniquely positioned to set expectations and provide direct coaching to staff because of their presence in units. Working alongside staff to pick a few items to improve upon can help facilitate buy-in and establish local safety culture. Changes to safety culture don’t happen overnight, but setting goals and incrementally working towards improvement is key. Clear and frequent feedback plus action plans should always accompany an initiative.” 

MD-Medical Data’s Lee pointed out the importance and value of the relationship between IPs and the C-suite in lowering the occurrence of HAIs by improving hygiene practices. 

“I don’t think we have done enough to improve hygiene compliance. We see HAI and antibiotic resistance back on the rise after COVID -19. Once again, infection prevention continues to move down the priority list for Administration. IPs need to have a seat at the table with Administration, Supply Chain, etc. and be recognized as an expense-reduction and revenue-producing opportunity. They need to be comfortable in presenting both a clinical and financial value proposition to the C-Suite.” 

Lee added, “IPs also needed to learn how to be comfortable with large data and analytics tools and seek to acquire these tools, such as hygiene-compliance technology. Additionally, IPs need to take a more synergistic, evidence-based and blended approach as suggested by SHEA (Society for Healthcare Epidemiology of America), where they say, ‘not one solution/intervention can move the needle on HAI, but a combination of solutions/interventions’ (i.e., terminal clean robot + hand-hygiene technology).” 

The costs of hygiene practices 

With many hospitals and healthcare facilities still trying to recoup profits lost during the pandemic, the desire for increased hygiene practices may fall victim to decreased budgets. 

UV Angel’s Lee remains optimistic and said, “I think you can have really good hygiene practices and be cost-effective, considering the cost of infections, the cost of employee absenteeism and replacing staff that is out due to illness. Beyond financial burdens, we also need to consider the patients that are getting infections while being in the facility’s care. If we can focus on the areas that are problematic, where infection transfer occurs, we can target specific areas where we consistently treat the air versus having to redo entire ventilations systems.” 

PICC Excellence’s Moureau added, “It is very easy to look to the use of antimicrobial products and sterile gloves or procedures to reduce infection and provide safety. Rather than accepting the sales message of product, cost accountability is achieved through value analysis and investigation of the root causes. Often education, while also a cost, results in improved outcomes and cost savings. Understanding when to perform low-level disinfection versus high-level disinfection, with more costly equipment, solutions and more time, will, in the long run, provide greater savings by doing it the most efficient way, rather than the easy way of adding a new product.” 

She continued, “Careful consideration is needed to be both sufficient and efficient with our practices so that money is not squandered on unnecessary products or practices. Cost savings are gained with percutaneous procedures of ultrasound-guided peripheral catheter insertions using low-level wipes, or even the less expensive high-level disinfecting foams for disinfection of the device before and after the procedure, and instituting most of all, education with accountability through observation of practices.” 

GOJO’s Rosenthal noted, “It’s understandable that in today’s environment, all healthcare facilities are watching expenses and trying to drive cost out where they can. But driving for the lowest price solution doesn’t always result in lower overall costs, especially if what you’re trading off is an increase in healthcare-associated infections or CMS reimbursement penalties.” 

She added, “What’s important for those in purchasing roles to know is that healthcare hand sanitizers are OTC drug products that are required by the FDA to meet specific efficacy targets with multiple uses. But not all hand sanitizers are created equally, as many learned during the pandemic. In the case of hand hygiene, cost per ounce or cost per use depends completely on how much of that product a healthcare worker must use to get the efficacy that the product is claiming. Savvy purchasers are aware of this and work closely with their IP colleagues to make sure products are evaluated accurately based on the data shared by each manufacturer.” 

MD-Medical Data’s Lee summed up, “Obviously cost is an important factor when it comes to improving and sustaining high quality and safety. I would ask IPs to become familiar with presenting the financial and clinical value proposition to Administration. If they don’t feel comfortable doing this, ask for help. The investment that an acute care site might make into a several technologies should be balanced against the savings associated with cost of infection. A technological approach can save 50% to 75% on cost of infection. The ROI is substantial. One hospital system in Florida was going to spend $100 million over the next five years, and none of this was reimbursable. To summarize, the right technologies save lives, save money and are safer for staff and patients.”