Coming Clean On Hand Hygiene

Recently, The Joint Commission (formerly The Joint Commission on the Accreditation of Healthcare Organizations [JCAHO]), announced plans to attack the national epidemic of hospital-spread infections by launching a nationwide hand hygiene campaign. To the uninitiated this sounds like a good idea that is long overdue. However, the data as to the effectiveness of such an approach in controlling hospital-spread MRSA (the most egregiously out-of-control hospital bug) can present a picture that may not fit with that initial reaction.

Below are examples from a report published in Eurosurveillance, Volume 14, Issue 17, 30 April 2009, titled "National Hand Hygiene Campaigns in Europe, 2000- 2009"

(http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19190)

The countries in this report with the lowest rates of MRSA have no national hand hygiene campaigns but routinely use active detection and isolation (ADI) for MRSA. On the other hand, the UK, which has had some of the highest rates of MRSA in Europe, has had a comprehensive hand hygiene campaign since 2004. And if we are to believe some of the statements coming from some gov’t officials, England’s MRSA rates only declined over the last couple of years after rolling out active detection and isolation programs targeting MRSA. There is no doubt that hand hygiene is a very important component in controlling hospital-spread disease. But the examples below strongly support the conclusion that MRSA can not be controlled with hand hygiene campaigns alone, whereas MRSA has been successfully controlled when routine active detection and isolation is used, even without a national hand hygiene campaign.

Denmark. No national campaign has been held so far, but individual, hospital-based campaigns exist. In 2008 the National Board of Health and Statens Serum Institut organised a survey of local campaigns, with regard to their design, resource availability and indicators used for compliance evaluation. A educational hand hygiene website (www.ssi.dk/hygiene) was created in 2002 and updated in 2004. It is available for all healthcare institutions to use when they want to create their own local campaigns. Among other information it offers downloadable material and posters for purchase The website has also been translated into English

Finland. There has not been a national campaign, but many regional and local activities for hand hygiene exist, which are supported financially by the government. These activities include training for HCW, a video on hand hygiene provided by the Finnish Society for Hospital Infection Control and an e-learning course on infection control (http://www.sshy.fi/). In addition, several regional campaigns have taken place in acute care and long-term care facilities, focusing mainly on hand hygiene.

The Netherlands. No national campaign has been organised yet, but there have been many active regional campaigns targeting HCW only. These campaigns included media activities such as press releases, television programmes, leaflets and posters as well as a dedicated website (www.handhygieneredtlevens.nl and www.gewoonhandenschoon.nl). Support was available from NGOs, the hospitals themselves and the industry, including pharmaceutical companies and ABHR manufacturing companies. Regional support was available for auditing of compliance with hand hygiene. ABHR were increasingly available in hospitals during the campaigns. Data on consumption of ABHR and on compliance with hand hygiene is available but not yet published.

Sweden. No national campaign for hand hygiene has been held, but regional campaigns are quite active. Regulations from the National Board of Health and Welfare on hand hygiene exist and implementation of these regulations is organised locally. Educational activities for HCW, local hand hygiene campaigns, measuring hand hygiene compliance and also measuring consumption of ABHR are the main foci of Sweden’s local campaigns and practices. Results from a questionnaire sent to HCW and healthcare institutes in 2007 showed poor hand hygiene compliance ( www.socialstyrelsen.se/Publicerat/2007/9835/2007-10-103.htm )
Sweden is organising a national project to support infection control and hand hygiene in long-term care facilities.

United Kingdom
In 2004, the National Patient Safety Agency (NPSA), initiated the ’cleanyourhands Campaign‘ within the National Health Service (NHS) in England and Wales (www.npsa.nhs.uk/cleanyourhands/). There are plans to continue the campaign until 2010. Funding for the campaign comes from the Government with additional support from suppliers of hand hygiene products. The campaign is supported by additional organisations including the NHS Purchasing and Supply Agency (now NHS Supply Chain) and the Infection Control Nurses Association (now the Infection Prevention Society). The campaign targets HCW with the provision of ABHR at the point of care, posters, press releases, leaflets, education and training resources, and its dedicated website. Involving patients is also part of the campaign, with some materials featuring the message ‘It’s OK to Ask’. In 2009, a series of training workshops on the WHO ‘Five Moments for Hand Hygiene’ (http://www.who.int/gpsc/tools/Five_moments/en/index.html) are taking place, supported also by other resources including a DVD. A pilot project has been started, designed to empower patients to improve compliance of HCW with hand hygiene. Data on compliance with hand hygiene and on consumption of ABHR can be downloaded from: www.idrn.org/nosec.php.
In 2008, the Department of Health Social Services and Public Safety in Northern Ireland linked with the NPSA and launched the ’cleanyourhands Campaign’ (www.dhsspsni.gov.uk/cleanyourhands).
In Scotland, the hand hygiene campaign ’Germs. Wash your hands of them‘ (www.washyourhandsofthem.com) was launched in 2007 by Health Protection Scotland (HPS). An audit tool and supporting protocol are used by Scotland’s 14 NHS Boards, and data for hand hygiene compliance from all NHS Boards is reported quarterly and can be downloaded from: http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx. Previous targets for compliance set by the Scottish government have been met and exceeded, and now a zero tolerance approach is being taken by all NHS Boards towards non-compliance with hand hygiene.

And here’s something for all the proponents of "hand hygiene is the answer", and those who may be on the fence: at the University of Geneva Medical Center, hand hygiene has been a focal point for many years. For starters, everyone entering the institution is greeted by a HUGE billboard promoting hand hygiene. Inside the hospital, the corridors, elevators, and rooms are all decorated with signs, cartoons, and other graphics promoting the importance of hand hygiene. The institution has 15 full time infection control professionals (ICP), spends about $100,000 annually on hand hygiene education, etc, and the CEO daily walks through the units handing out awards to those health care workers who are observed in compliance. Yet, with all of this, the highest rate of compliance with hand hygiene that they have ever achieved is 67%!

Now, ask yourself; What is the likely impact from such a program on infection rates in US hospitals, which employ perhaps 1 ICP and 40% are having their infection control programs’ budgets reduced? Perhaps that is why Switzerland, which has kept their MRSA rates down below a fraction of 1% through routine use of ADI, is not interested in spending their resources on a national hand hygiene campaign.

While it makes sense that if every care giver practiced proper hand hygiene 100% of the time, and all equipment was properly sterilized 100% of the time, infections would go down to almost zero. Then again, it only takes one negligent healthcare worker to infect any number of patients. When the greatest compliance rate with hand hygiene that has ever been achieved with an aggressive campaign in a serious clinical study has been 80% (2-3 months long), why on earth would anybody rely solely on a hand hygiene PR campaign to prevent illness and death?

The push for hand hygiene in this country was and remains a diversion that is also meant to pacify consumers and government officials. And since it is being proposed by "leaders" in the field of public health who know things like all that which is mentioned above, it seems clear to me that their intention is not to do what is best for patients.

If The Joint Commission’s new "comprehensive approach" to attack hospital-spread disease does not include what we know works, then you can best believe that they are not serious about the issue.