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Patient room notes, pop quizzes boost hand hygiene

Rapid testing of interventions help a health system figure out how to remind doctors, nurses and other health professionals to wash up.

By Kevin B. O’Reilly — Posted Feb. 29, 2012

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A note on the white boards in hospital patients' rooms saying, "I like clean hands," can result in higher rates of hand-washing among health professionals, but a sign in the staff lounge urging hand-hygiene compliance probably will not make a difference.

These are among the findings of a rapid intervention-testing process used at seven hospitals in the Sentara Healthcare system, headquartered in Norfolk, Va., that pushed the hand-hygiene compliance rate to 92.5%. The nationwide hand-washing rate has hovered around 50%, depending on the study and measurement used.

Like many health systems, Sentara finds itself under pressure to improve hand-hygiene compliance rates that have been linked to nosocomial infections. Rates of such infections are being publicly reported, and many insurers withhold payment for treating some infections acquired in the hospital.

Sentara already had easily accessible sinks and sanitizer foam, yet a revised audit process had shown its compliance rate at about 75%. Officials had thought the rate was closer to 95%.

The auditing was previously done by health professionals who may have overestimated the amount of hand-washing occurring because they monitored their own hospital area while completing other job duties. The revised system sent health professionals to monitor other work areas and focus on monitoring hand-hygiene compliance.

"Hand hygiene has the most linear connection there is between a process and patient safety," said Gene Burke, MD, Sentara's executive medical director. "This is like apple pie and motherhood."

Last summer, Sentara gathered 83 health professionals from its hospitals to brainstorm fast and cheap ideas that might help drive up hand-hygiene rates. The system hired QualPro, a Knoxville, Tenn.-based consulting firm, to help test and analyze 21 interventions in 48 nursing units.

Interventions tested included computer screen savers encouraging hand hygiene and Hero of the Month awards to people who achieved high compliance rates. Different combinations of interventions were tested over six weeks in different units to provide a kind of rolling controlled trial.

Pop quizzes help hygiene

A second round of testing was done in 32 nursing units with the interventions that had proved the most effective. In addition to the white-board notes, putting up red stop signs to remind physicians and other health professionals to clean their hands was helpful. Another method that worked was giving a written hand-hygiene quiz to any health professional randomly stopped by a department leader or other executive.

"Everybody was fair game for these quizzes," Dr. Burke said. "If you were physically in the unit -- if you were someone who could transfer bacteria or a virus -- you were a target. ... You can't do this stuff with only nurses."

Interventions that work can vary by unit or by hospital, Dr. Burke said. Just because pop quizzes worked at Sentara does not mean they will be especially helpful in other systems.

"You can't make extrapolations," he said. "What has worked in our culture wouldn't necessarily transfer somewhere else."

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