Breaking News: When One Hand Doesn't Wash the Other

Ok, this doesn't really apply to us unless we are medical practitioners. I remember getting a squeeze of Purell when I entered the PT sanctum and one handedly trying to get it to dry.
http://journals.lww.com/em-news/Fulltext/2011/07000/Breaking_News__When_One_Hand_Doesn_t_Wash_the.5.aspx
Who knew hand-washing could be so controversial? Donald M. Yealy, MD, didn't, but he does now.


Image...

Image ToolsWhen UPMC Presbyterian in Pittsburgh mounted a campaign to improve compliance in hand-washing with threats of stiff fines, the concept made its way into the media, with claims of thousand-dollar penalties being slapped on doctors who didn't comply. The reports were wrong, said Dr. Yealy, the chair of emergency medicine there. When a headline on one such article posed the question: “Fining Unwashed Hands — A Dirty Trick?” physicians lashed out. “At Utopia General Hospital, everyone who has patient contact washes their hands thoroughly before and after every encounter. I don't practice there. I practice in the real world,” one observed. (http://bit.ly/WashFine.)

No fines were actually implemented at UPMC Presbyterian, and were only to be imposed when the lack of hygiene occurred despite clear markings of the patient room and notice by a trained infection control employee. Since announcing the approach, no one failed to abide by the precautions or received a fine, and a recent pathogen outbreak was quelled, Dr. Yealy pointed out.

The effort at UPMC Presbyterian, which also involved “modeling” by physician and nursing leaders who washed hands prominently during patient care, helped increase compliance in the emergency department from below 50 percent to above 80 percent.

The Centers for Disease Control and Prevention has called hand-washing the most effective preventive measure for preventing hospital-acquired infection. But apparently it doesn't take much to get the negative feedback started on the subject of clean hands for safety's sake. After the New York Times published a seemingly objective and scientific look at the matter — explaining the dismal record of hand-washing in many health care settings and noting that new methods such as alcohol-detecting lapel badges that record a staff member's sanitation status might help boost the habit — readers from the health community posted messages both critical and defiant. (http://nyti.ms/kcM3Up.)

One took issue with the white coats and hospital gowns that are supposed to represent cleanliness, asserting the attire should be viewed as a possible source of contamination instead. “They wear their ‘scrubs' and other uniforms around infected patients in the hospital and then leave the hospital (wearing the garb), often getting onto crowded buses and trains. Doesn't this spread infections?” one wrote. Another complained that excessive hand-washing was injurious to personal health. “All winter, every winter, my hands hurt from cracks in the skin. Washing exacerbates this condition. Are there hospital workers who, like me, approach hand-washing with trepidation?”

The most frequently cited figure for adherence to hand-washing is 40 percent, and the most common reason for this low statistic is time pressure. (Infect Disease Clin North Am 2011;25[1]:21.) In fact, investigations show a direct relationship between hand-washing and high patient volume, according to Didier Pittet, a professor of medicine and the director of the disease control program at the University of Geneva Hospitals. He and colleagues have examined hand-washing in emergency and nonurgent care settings, and the relationship persists wherever it occurs, he said. (Emerg Infect Dis 2001;7[2]:234; http://1.usa.gov/lyGGmL.)

“Our findings suggest that habits cannot be overcome by reason [or] motivation alone, but instead the person needs to supplement the good intentions with specific ‘if-then' plans that spell out when and how they will break the habit,” said Thomas Webb, PhD, a lecturer in social health and psychology at the University of Sheffield in the United Kingdom.

Motivation is more complicated than is generally assumed. It involves several different internal questions: Can you do it, and are the resources available for doing it? Do you think it will work under these circumstances? And is it worth doing? It is the answer to that last question where motivation can crumble, said Scott Geller, PhD, a distinguished professor of psychology at Virginia Polytechnic Institute in Blacksburg.

Insurmountable interference — time crunch — may cause well-intentioned people like emergency physicians to answer “no” to that third question. “When no one is watching, self-motivation is essential,” he said. That's when personal ethics alone can spur correct acts. Severe stressors can quash that good intent, however. Say someone truly wants to protect patients from any possibility of infection, but is making a split-second decision to institute care instead of pausing for an alcohol wipe. If there are adverse consequences in addition to ethical considerations, the alcohol wipe is likely to be used, he said. This is why surveillance cameras at stoplights work. The same thing could apply to a medical setting, Dr. Geller noted.

In the UPMC Presbyterian emergency department, employees themselves monitored hand-washing, alerting each other when they didn't see it being done. But the hospital also hired ringers to pose as hospital staff and report hand-washing observations by moving round the hospital and ED without detection. “I never spotted any,” noted Dr. Yealy. “So apparently they really blend in.” The goal, he said, “was to raise the level of awareness and change behavior.”

The experience at UPMC Presbyterian has shown how placement of sanitizing stations can make a difference, he said. They seemed to serve as reminders to wash, and are most effective when put in high-traffic areas and in plain view at each bedside, Dr. Yealy observed. “I think it is really helpful to look at the engineering of hand-washing opportunities,” he said.

UPMC Presbyterian's hand-washing campaign is still underway. After all, even though compliance has doubled, “we want to get that last 15 percent or so,” Dr. Yealy said.