Hospitals have long been a place to which, ironically, germs and dirt gravitate. Despite staff members’ best intentions, some healthcare centres are barely fit for purpose. Hospitals across the world have attempted numerous measures to combat the issue of staff not washing their hands, often aimed at laziness or forgetfulness, with varying degrees of success. These efforts exist among campaigns to better educate the public, too, and to design better hospitals that are easier to keep clean by way of their functionality.
We have all seen them: those bathrooms that look positively space-age, where you don’t need to touch anything in order to wash your hands. No door handles, no button-push hand dryers – just lasers and sensors that can tell precisely what you need. It seems like a breakthrough in the battle of cleanliness versus human nature, and yet the technology is pointless if not actually used. Research published in 2014 in the Journal of Applied Psychology revealed that healthcare workers only washed their hands on 42.6% of the occasions they should have; further reduced to 34.8% by the end of a 12-hour shift.
The figures are quite surprising, considering that many of these bathrooms are designed with major emphasis being put into ease of use and staving off contamination. Such reminders are evidently falling on deaf ears, and many researchers are directing focus towards finding out whether it is the result of stressed, tired doctors and nurses simply forgetting to wash as thoroughly – or at all – or genuine laziness. There is evidence to suggest that requiring less effort from staff may get results, with small increases in hand-washing adherence seen after some hospitals implemented alcoholic hand rubs that decreased the effort needed to wash hands.
Figures from the UK’s National Institute for Health and Care Excellence (NICE) show that one in 16 people admitted to hospital will pick up an infection unrelated to their illness. According to numbers available in the US, in 2011, an estimated 722,000 patients contracted an infection during a stay in an acute-care hospital and about 75,000 of those died as a result. With such large numbers, it is obvious that infections and deaths caused by lack of hand washing are part of a larger problem. Whatever the reason, there are several schools of thought on how to fix it, and one is the development of new machines.
Health and surveillance
Dr Jocelyn Srigley is associate professor of pathology at the University of British Columbia, and the director of infection, prevention and control at the provincial government’s Health Services Authority. She believes that while new machines are a good idea to catch those few who are genuinely forgetful, other ways of reminding people are more effective, far less expensive and would lead to a more cohesive way of building better hand hygiene.
Some hospitals use badges – worn around staff members’ wrists or necks – that are able to detect whether the wearer has used alcohol gels before and after seeing patients. The high-tech hand-washing and detection equipment is also capable of identifying members of staff who infrequently wash their hands. Srigley sees the benefits of this system, but is sceptical of its overall usefulness.
"One of the challenges of electronic monitoring systems is that there may be resistance among staff due to privacy concerns," she posits. "The systems can also be quite expensive to install and maintain."
These badges are often used in conjunction with hand-washing machines that wash up to the wrist in just 15 seconds, getting rid of almost all pathogens. The machines give a consistent quality of hand-washing, use green technology and consequently less water, and don’t affect the skin’s natural bacterial balance. The biggest plus, however, is that hospital managers can also monitor workers’ hand-washing activity – the machine records the identity tags worn by users.
There are many who believe this sort of monitoring will have a positive effect on hospital infection rates in the long term, but only if used in conjunction with better management of hospitals overall. This includes such issues as tackling overcrowding, and improving hand hygiene more specifically in relation to catheters and intravenous lines. Moreover, while this monitoring system is seen as progress, it has not been as successful as hoped. Srigley claims that this is because hand hygiene must be taught, rather than observed.
"I was involved in a systematic review of electronic monitoring systems and there isn’t much evidence to date that they improve staff hand hygiene," she says. "They can be useful as a measurement tool and they have many advantages over direct observation, but on their own they aren’t enough to change behaviour. Some systems are able to remind staff to perform hand hygiene, such as through voice prompts or vibration, and these might help – but they haven’t yet been shown to be effective in high-quality studies.
"If the goal is to improve hand hygiene, I wouldn’t advocate an electronic monitoring system, given those issues and the fact that we don’t have any evidence that they change behaviour," Srigley continues. On what she thinks is the best way forward, she says, based on her own research: "Hand hygiene interventions that focus on behaviour change and organisational culture have much more potential to bring about improvement, can be done with minimal resources, and can enhance team functioning."
Supervised scrubbing
Srigley sees the future lying in behavioural programmes such as studies of the Hawthorne effect, or ‘observer effect’, through which members of a group are coerced, through watchfulness from the rest of their peers, to lead better practices: a slightly nicer version of peer pressure, effectively. Applied in the workplace, such programmes are assumed to inflate hand-hygiene compliance rates through the pressure of being observed.
"One project used an electronic system to measure the Hawthorne effect," she continues, "and we found that hand hygiene increased by about 300% when there was an observer present, suggesting that true hand-hygiene rates are much lower than what is being reported by auditors.
Her research on this subject is ongoing; she hopes to do more in the future to get a richer picture of how to enhance patient safety. "In the study on the Hawthorne effect, we weren’t able to track specific groups of staff," she explains. "Other studies have reported that doctors have worse hand hygiene than other groups, but I suspect doctors aren’t as susceptible to the Hawthorne effect and therefore don’t change their hand hygiene behaviour when there are auditors around, while other groups do."
Srigley is also investigating patient hand hygiene, and believes there needs to be a wider scope of research.
"There has been so much focus on healthcare worker hand hygiene, but we often forget that patients can also pick up microorganisms on their own hands," she says. Results of a study Srigley was involved in show that patients "performed hand hygiene about 30% of the time when they went into the bathroom and 40% of the time during meals". Evidently, patients and healthcare workers alike need help to improve hygiene. Srigley believes more engagement is key to achieving this.
A clean future
It is not all negative in terms of practices: Srigley has seen advances around this issue. There is, she says, an "increasing awareness that patient hand hygiene is also an important factor", and thinks we will therefore see more research and guidelines on patient hand hygiene in the near future. She says there is also now more interest in moving beyond the standard multimodal programmes, incorporating elements of behaviour change and organisational culture into ways to combat healthcare-associated infections. "Strategies like front-line ownership and positive deviance are being used more," she explains.
"I think that changing the organisational culture to promote frontline ownership is essential to improving hand hygiene," she concludes. "All healthcare workers have an important part to play in preventing healthcare-associated infections – it’s not just the job of the infection prevention and control team." She thinks front-line staff-members are the ones who know best how to implement infection-control strategies that will work for their settings. "We in infection prevention and control need to stop being the ‘hand-hygiene police’, and instead help the front-line staff to take ownership of the issue and facilitate implementation of their solutions."
Whatever the solution to encouraging hand hygiene, it’s sure to be a long process – and one that will involve more than just a new type of machine.
