Hands Off the Merchandise

You may think of it as the first week of Christmas, but there are some out there that think of this first week of December as National Handwashing Awareness Week.  Pay attention Hallmark–another greeting card opportunity is upon you.  I’m sure the one you sent me, blog reader, is in the mail.

Christmas has Santa Claus and National Handwashing Awareness Week also has its own mascot, Henry the Hand.  Henry (we’re going to be on a first name basis for this post) is the representative of one Dr. Will Sawyer, who founded the Henry the Hand Foundation in 1999 after years being completely grossed out, it seems, by his fellow medical colleagues, who despite having had mothers, some of them even Jewish, simply cannot remember to wash their hands before touching a patient in the hospital.

Dr. Will has been out there waving his Hamburger Helper logo lookalike in an effort to promote a culture of patient safety through his Champion Handwasher Hospital Campaign, a program that helps hospitals improve hand hygiene through a multi-faceted program that includes healthcare worker education, patient feedback, friendly competition and the use of humor.  I’m not sure why Dr. Will and Henry are laughing given the statistics:  according to MedPage Today, 2.5 million patients develop [avoidable] healthcare-associated infections annually, resulting in 90,000 deaths annually at a cost of as $4.5 to $5.7 billion (but who’s counting?).  Instead, maybe Henry should be packing a box of Kleenex to wipe his tears and traveling the country slapping healthcare workers silly.

It really doesn’t take a medical degree to know that hand washing is the most effective, lowest tech and lowest cost way to reduce avoidable hospital acquired infections.  Most of us have been taught since childhood to wash our hands when we use the bathroom so we have a pre-existing well of knowledge to draw from (thanks mom!).  Everywhere you look in a hospital there’s a sink (in every patient room and often every few yards in hospital unit hallways as well).  Nowadays you also find stations that dole out hand sanitizer nearly everywhere one might find a patient.  Thus, it isn’t for lack of resources that hospital workers so often fail to take this simplest of safety steps .

If you could visualize the most germ-infested place in the nation, I’m guessing many of you might say the public restroom at the average sporting arena or roadside gas station.  And yet in September 2010, Michael Millenson, a visiting scholar at the Kellogg School of Management, compared data from a recent survey of public bathroom hygiene in the U.S. to hand hygiene compliance rates in U.S. hospitals, and found that “the guy who just used the toilet at Grand Central Station is … way more likely to have clean hands than the guy walking up to your bed at the local hospital.”

Writing in The Health Care Blog, Millenson noted that a recent survey by the American Society for Microbiology and the American Cleaning Institute found that on average, 85 percent of adults washed their hands after using a public restroom.  He compared that rate with a finding from a 2009 American Journal of Medical Quality (AJMQ) study, which measured an appallingly low 26 percent hand hygiene compliance rate for Intensive Care Units, notable for being the location in a hospital where the most impaired, frail patients are housed.  The same study found that there was a 36% hand hygiene compliance rate for hospital units outside the ICU, if that makes you feel any better (it shouldn’t).

Another 2010 study done by Applied Nursing Research found that 34 percent of healthcare workers wash their hands in situations where they are supposed to do so, so this is not an anomaly.  Note that the AJMQ study quoted above found that after 12 months of measuring hand-washing rates, providing tools to improve compliance and providing active feedback, compliance increased to 37% for ICUs and 51% for non-ICUs.  Not exactly something to cheer about.  I can see the Hallmark card now:  Hey Doc, thanks for washing your hands about half the time!  Happy Hand Washing Awareness Week!

So the bottom line is this, random guys at truck stop bathrooms have a better batting average on the handwashing front than Barry Bonds at his juiciest (pun intended) while doctors and nurses are hitting like Pedro Feliz in the same game.  Pedro and his.218 batting average got cut from the World Series winning Phillies and exiled to St. Louis, so let that be a lesson to them.  And, speaking as a person who was actually in the hospital this year (nothing serious as it turned out), that is totally nasty.

There is some promising news, I suppose.  The Joint Commission on Accreditation of Hospital Organizations (JCAHO) piloted a quality improvement project at 8 hospitals that successfully managed to raise hand hygiene compliance rates from a baseline of 48 percent to a sustained average of 82 percent between April 2009 and June 2010.  That is definitely a step in the right direction, enabling those 8 hospitals to reach parity with male handwashers vs. male non-handwashers in the public restroom at the SF Ferry Building (81% are handwashers according to this study), but a far cry from females at Atlanta’s Turner Field (home of the Atlanta Braves), where 98% washed their hands after using the very likely inadequate number of public restrooms (see this study from the American Microbiology Society for the details on these stats).  If we are truly going to strive to eliminate infections caused by failure of healthcare workers to adequately wash their hands, we are going to have to shoot for that Atlanta number, as much as I prefer San Francisco.  Nevertheless, JCAHO should be lauded for its efforts to spread this new patient safety-focused Targeted Solutions Tool throughout the United States.

But harkening back to that Applied Nursing Research study, which looked at the hand-washing practices of 67 providers over the course of 16 weeks and 612 procedures performed at an oncology hospital, it is particularly notable that compliance with hand washing was found to be better for doctors after procedures (72 percent) as opposed to before procedures (42 percent), something the authors of the study believe indicates less of an urgency to protect patients from disease. “These findings may suggest that healthcare providers are probably driven to wash their hands by their need to protect themselves more than their patients,” the authors observed.

So maybe JCAHO, hospital leaders and Henry are going about this all wrong.  Rather than appeal to healthcare workers’ guilt and professional ethics by marketing campaigns focused on improving patient safety, they should direct the public relations machine elsewhere toward provider self-interest and self-protection.  Rather than signs prodding physicians and nurses to make patient safety a priority, they should remind them that their own security is on the line for failing to do the right thing.  I can see the Hallmark card now:  Hey Doc, Wash Your Hands: the Butt You Save Will Be Your Own!  Happy Hand Washing Awareness Week!

I have another idea. You know those hideous gowns you get when you are admitted to the hospital.  I think I’ll fashion a new line of these emblazoned with the words, “Hey! Don’t Even Think About Touching Me Unless You Washed Your Hands.”  On the back, where the sliver of your butt used to show, it can have a nice modesty flap that says, “Happy Handwashing Awareness Week!”