Safety Sciences

Hand Hygiene Compliance - Should we Settle for just 40%?

Systematic Review of Studies on Compliance with Hand Hygiene Guidelines in Hospital Care.

Erasmus et al. Infect Control Hosp Epidemiol 2010; 31: 283 - 294

We've all heard that hand hygiene is important to prevent healthcare associated infections. And we've also heard that in most hospitals, hand hygiene compliance is poor. In 2004 an editorial commented that in the United States " hand hygiene rates average 40 - 60% on a good day." (Weinstein 2004) We now have an article available that tells us exactly how poor hand hygiene compliance is in hospitals, based on published studies. And Weinstein's range seems to be fairly accurate.

Performing a comprehensive search for published articles that described compliance with hand hygiene in hospitals from countries with 'established market economies', these authors identified a final set of 96 articles. In these articles compliance with hand hygiene guidelines was assessed either by directly observing healthcare workers (90% of articles), or by self-reporting by healthcare workers. 

Compliance was defined as the percentage of time healthcare workers cleaned their hands when they were supposed to (a 50% compliance means that healthcare workers cleaned their hands during half of all the times they were supposed to clean them). In two-thirds of these articles hand hygiene compliance was studied in intensive care units. Most of these articles were from the US, Canada, Europe and Australia.

The reported compliance across studies ranged from a low of 4% to 100%. Ranking the results from all the studies and for all types of healthcare workers (meta-analysis could not be done), the median hand hygiene compliance rate was only 40%. This means that in half the studies, healthcare workers cleaned their hands less than 40% of the time. In three-fourth of the studies, hand hygiene compliance was 50% or less. In other words, only a quarter of the studies found compliance rates higher than 50%. Even for the subset of ICU studies, the results were pretty similar: the median was 40 - 50%, and 72% of studies reported a compliance of 50% or less. 

What about differences between doctors and nurses? Although the authors of this review did not report direct comparisons of physicians with nurses within each hospital, it seems that hand hygiene compliance is worse among doctors than among nurses. There were more published studies reporting that doctors were poorly compliant than were studies reporting that nurses were poorly compliant . Specifically, if we define 'poor hand hygiene compliance' as a compliance rate less than 50%, almost 80% of studies in this review found that doctors were poorly compliant, whereas almost 60% of studies found that nurses were poorly compliant.

This review and the included studies had some limitations. The included studies were heterogenous in their methods (hence a meta-analysis could not be done) and often did not report the specifics of how observation of hand hygiene was performed. Many of them used direct observation and self reporting to measure hand hygiene compliance which are not the ideal methods of measurement. Healthcare workers may change their behavior if they are being observed by hand hygiene auditors. But if this happened, one would expect the measured hand hygiene compliance to be falsely high. The fact that the reported compliance rates were so low in spite of directly observed measurement is alarming, because unobserved rates then are presumably even lower.

Reference

Weinstein RA. Hand hygiene - of reason and ritual. Ann Intern Med 2004; 141: 65-66

What's in a Name........?

Categorizing Errors and Adverse Events for Learning: A Provider Perspective. Ginsburg L et al. Healthcare Quarterly 2009; 12: 154 - 160

'Near miss,' 'medical error,' adverse event,' 'harm,' 'preventable adverse event,' 'variance,' 'sentinel event' - a bewildering number of terms like these is used in patient safety to indicate different types of events. (An umbrella term for all these is 'patient safety events.') Often there is confusion among health professionals about what to call an event or an incident and much misunderstanding may result from this. 

To understand what front-line providers and managers thought about such terms, and to identify which types of events they thought were most suitable for learning in order to improve patient safety, the authors of this paper conducted focus groups with patient safety officers, patient care managers, nurses and other allied health professionals. 

The authors presented the following categorization of events to the participants: (1) near misses, (2) preventable adverse events causing minimal harm but no prolonged hospitalization, (3) preventable adverse events that resulted in prolonged hospitalization but no permanent harm to the patient and (4) sentinel events (events that resulted in permanent disability or death).  The focus group participants:

1. preferred a simple classification of events into 'major events' and 'minor events,' with a further sub-classification of the events by the degree of harm that was actually observed or could have occurred. They did not like the above categorization - it was not intuitive, was too fine-grained, and too restrictive. 
2. believed that preventable events should be the focus of learning opportunities, as opposed to non-preventable events (such as an allergic reaction to a medication that occurs for the first time).
3. thought that near-misses were an important way of learning how to improve patient safety.
4. disagreed on which type of events were more valuable for leaning - events actually causing severe harm, or those that could have caused severe harm (but did not). 

Other findings from the focus groups were:

• Attribution of harm to an event is sometimes difficult. For example, it may be difficult to determine whether an event truly caused prolonged hospitalization or whether the disability it caused is permanent.
• Preventability might be hard to determine in certain cases. 
• The word 'preventable' is bothersome because it implies that the health professional is at fault, and not other aspects of the system.
• Near-misses are often unreported or unnoticed, and are complex to identify and categorize.
• Near-misses should be categorized based on the severity of the harm that could have resulted, and how close to the patient they were caught.
• When an even causes serious patient harm, it can lead to significant and long-lasting learning, but can be hard to discuss. In contrast, near-misses that could have potentially caused harm are easier to discuss, but may not be taken as seriously as actual catastrophic events.

Based these results, the authors developed and refined a new typology of patient safety events, to be used for all patient safety events except those that are clearly non-preventable: 

Minor Event: An event involving no harm or very minimal temporary harm to the patient 

Moderate Event: An event that causes discomfort sufficient to interfere with usual activity and requires additional specific therapeutic intervention, but poses no significant or permanent risk of harm to the patient. 

Major Event: An event involving death or serious physical/ psychological injury.  

Minor Near-miss: An event that would have resulted in no harm or very minimal temporary harm to the patient but did not because it was caught or because of good luck. 

Major Near-miss: An event that would have resulted in death or serious physical or psychological injury but did not because it was caught or because of good luck. 

Are Physicians like Cobblers with Bad Shoes? Part 1.

“The cobbler always wears the worst shoes” is a phrase that reminds us that physicians may not really take care of their own physical and emotional health. Such lack of physician self-care can have negatively affect patient care, the functioning of hospitals and clinics and the costs of healthcare. These topics are addressed by a recent Lancet article by Wallace and colleagues. 

In this article the authors point out that physicians commonly suffer from physical and emotional health problems, but are not good about seeking help and getting care for such problems. As a result they often function in a sub-optimal state of health and burn-out that can lead to low job satisfaction, increased turnover and low morale in the healthcare organization. More importantly, such ‘professional malaise’ leads to poor patient care, increased healthcare costs and medical errors. The authors propose that therefore the ‘wellness’ of physicians is an important quality indicator that healthcare systems should routinely track.

Here are the main facts that I gleaned from the article:

Frequency and Types of Health Problems among Physicians

Studies on physician health have mostly focused on illness. Such studies have shown that they often suffer from burnout, stress, depression, substance abuse and relationship troubles. In some studies, up to 75% of physicians were burnt out. Suicide rates are six times higher among doctors than in the general population. Doctors have a higher than average cardiovascular mortality. Stress and burn out are common among medical students and residents as well. 

However, health or wellness should not be considered just the absence of disease or sickness, but a positive state of well-being, including being challenged, thriving, and achieving success in various aspects of personal and professional life. Studies measuring this positive state among physicians are sparse, so we do not know exactly how often this ideal state is achieved. 

Reasons for Physician ‘Unwellness’

The reasons for physician illness and stress include external and internal factors:

External Factors

• Heavy workloads that are increasing over time (increased patient-care demands)
• Fatigue and sleep deprivation
• Having to deal with emotionally charged situations (that are associated with suffering, fear, failures and death)
• Difficult interactions with patients, families and colleagues
• High cognitive demands (the need to quickly process an overwhelming amount of information over long periods)
• Growing bureaucracy
• Increased accountability 
• Having to negotiate conflicts between the needs of the organization and patient needs, and 
• Loss of autonomy from restrictions on practice placed by external regulators and payors.

Internal factors

• Physicians commonly have certain personality traits such as perfectionism, workaholism and ‘Type A’ attitudes. These traits are associated with burnout, depression, anxiety, eating disorders and cardiovascular disease. 
• Female physicians often have to balance work and family responsibilities, which can increase work-family conflict and stress.
• Immigrant doctors can suffer from additional stressors and strains in addition to the stressors experienced by all trainees and physicians.

[to be continued.........]

Reference

Physician wellness: a missing quality indicator.Wallace et al. Lancet 2009; 374:1714