Blue Ribbon Abstract Award: A Systems Approach to Improving Hand Hygiene on an Inpatient Surgery Unit

Abstract

ISSUE: Low hand hygiene (HH) adherence rates have been linked to transmission of nosocomial pathogens. We thus set out to improve HH rates among all healthcare workers in an inpatient surgery unit by applying principles of the Toyota Production System to routine work of patient care. PROJECT: Baseline data were obtained by observing healthcare providers during patient encounters, revealing low HH adherence rates. Follow-up surveys, focus groups, and individual conversations were conducted to assess healthcare workers' knowledge, attitudes, and beliefs about pathogen transmission. Training addressed misunderstanding about the need for HH, hand-sanitizer effectiveness, and appropriate gloving. Improvements were made to the physical environment, including water pressure control and hand sanitizer instructional labeling and location. Assertiveness training addressed cultural barriers that inhibited feedback between healthcare workers regarding HH practice. A sign was placed in each patient room that encouraged patients to remind healthcare workers to perform HH. Staff also received weekly feedback about their unit-specific infection and colonization rates. Follow-up observations were conducted 5 months following initial observations. RESULTS: HH adherence data were collected during observation of 333 pre-intervention patient encounters and 420 post-intervention encounters. During encounters with patients requiring only Standard Precautions, pre-intervention HH adherence upon room entry and exit was 7% and 31%, respectively. Adherence improved to 51% and 70%, respectively, following the intervention (p=<0.001 for both). During encounters with patients on Contact Precautions there was no change in entry HH (24% versus 22%; p=0.52), while exit HH improved from 66% to 75% following the intervention (p=0.05). LESSONS LEARNED: A systems approach can improve HH if it addresses all the healthcare workers' needs for 1) understanding principles of pathogen transmission; 2) availability of hygiene materials and a supportive physical environment; 3) rapid feedback on results linking HH to patient outcomes; and 4) recognition of cultural factors affecting HH.