Preventing infections again hit the headlines this week with the latest report on antibiotic resistance, highlighting that infection prevention - both in hospital and home and everyday life - is key to tackling this problem, by reducing the need for antibiotic prescribing. Intriguing opinions are expressed by Professor Sanjay Saint, University of Michigan as to why we do not wash our hands.
Indications are that, up to 70% of hospital infections could be prevented by good hygiene which includes hand hygiene. Professor Saint says “it often seems that getting health care workers to follow hand hygiene protocols has gotten only slightly easier since the days of Ignaz Semmelweis. Although Semmelweis attempted to spread these hand hygiene practices – even confirming their effectiveness through intervention studies - he was largely ignored and ostracized. Today, we know that germs spread disease and that hand hygiene is critical but that doesn’t mean we are hand washing often as we should. A 2010 of hospitals around the world reported that just 40% of healthcare workers complied with recommended hand hygiene guidelines
So - Why is it so hard to get health care workers to wash their hands? The bvious reasons include lack of access to sinks or alcohol dispensers. Some may still need convincing that hand hygiene is important, and for some hand hygiene may simply be overlooked given other tasks demand greater attention. But Professor Saint also highlights other interesting barriers identified from his research.
He found that opposition to infection prevention initiatives comes from a type of health care worker classified as an Active Resisters. These are people who like doing things a certain way for the simple reason that things have always been done that way. During a site visit, an infectious diseases doctor said Getting the surgeons to adopt things in general is problematic … they’re like baseball players, they’ve got superstitions…in their minds if it’s working, why should we change it.
The second type, he calls organizational constipators. These individuals often have nothing against an initiative per se but simply enjoy exercising their power by refusing to change. The challenging aspect about organizational constipators is that the people above them think they are doing a good job, while those below them cannot believe they still have a job.
Another barrier is that many hospitals have a culture of mediocrity, rather than a culture of excellence. These hospitals are content to be just good enough. Leadership is generally ineffective. Overperformers are rewarded with more work.
Professor Saint also discusses the specific steps which have been found to improve compliance. He believes that probably the most important single thing is investing in alcohol-based handrub. When they introduced personal bottles of handrub in an Italian hospital, they found adherence rates increased from 28 to 47% for doctors, even a year after the intervention. When personal bottles of handrub were introduced at University of Geneva, compliance improved from 48 to 66 % while the hospital infection rate decreased from 16.9 to 9.9%.
One intensive care unit installed video cameras with views of sinks and handrub dispensers and found an eightfold improvement in hand hygiene compliance when remote video auditing was combined with data feedback. The data were updated every 10 minutes on LED boards in the hallway. Professor Saint said “I suspect it was the combination of being monitored and seeing real-time data, similar to how seeing the car speed flashing on a monitor on the side of the road helps remind us to stay under the speed limit, that made the difference”.
More recently, another hospital reported hand hygiene compliance rates of over 95% by enlisting front line health care personnel to provide immediate positive and negative feedback to colleagues. Such peer pressure from colleagues likely helped overcome both active resistance and organizational constipation.
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