Clinician, wash thy hands: When the patient becomes the enforcer

As an intensive care physician at a hospital in Saskatoon, Dr. Susan Shaw is both comfortable and confident in the health care setting. But when she recently had to bring her daughter to the emergency room with a broken arm, “I couldn’t do it,” she blogged recently. “I couldn’t ask the nurses and doctor who looked after my daughter to wash their hands.”

If she was uncomfortable speaking up, what about the average patient and family?

Dr. Shaw’s experience illustrates an important and often overlooked issue in patient safety: the gap between what patients and families are told to do – “Remind providers to wash their hands” – and their willingness and/or ability to actually do so.

Hand washing is one of the key ways clinicians can avoid spreading germs to their patients and reduce the risk of infections acquired in the hospital setting. Yet health care workers often are inconsistent at washing their hands. In various studies that have attempted to measure hand washing compliance, the rate at some hospitals has been estimated at an abysmal 25 to 30 percent. Some studies have measured especially low rates among doctors and medical students.

No wonder, then, that patients and families have been enlisted in the campaign to help clinicians do better. But is the public any more successful in the role of enforcer than hospitals, medical clinics and nursing homes have been? It seems the answer is no.

A study that appears this month in the Infection Control and Hospital Epidemiology journal queried 200 patients about their awareness of the importance of hand washing and whether they would feel comfortable reminding nurses and doctors to wash their hands. The patients, all of whom were considered at higher risk for infections such as methicillin-resistant staph, were highly aware of the need for hand washing – but only 14 percent said they had ever spoken up and asked a health care worker to wash their hands. Moreover, only about half said they wouldn’t feel awkward asking a doctor to wash his or her hands.

Why such a gap between theory and practice? Based on her own experience, Dr. Shaw suggests some reasons:

I was worried about making the doctor and nurses feel uncomfortable. I knew my daughter’s care wouldn’t be compromised if I upset the doctor and nurses. I just didn’t want any awkward feelings.

Readers weighed in with similar stories of being too uncomfortable to ask – or of asking and being met with a grudging response. One person wrote, “When I did ask a nurse if she had washed her hands, I was greeted with a look that said to me I had been labeled a ‘difficult family member.'”

Indeed, more than a few health care professionals believe it’s not the patient’s or family’s place to remind them to wash their hands, as a study published a few months ago in the Archives of Internal Medicine concluded. Nearly one-third of the doctors and nurses who were surveyed said it was inappropriate for patients and families to have a role in this, and almost two out of five said they wouldn’t wear a button or sticker urging patients to ask them if they washed their hands. The reasons they gave: 43 percent said a reminder from a patient or family member would make them feel guilty, 27 percent said it would be humiliating and about 25 percent said having to stop and wash their hands in response to prompting by the patient would take too much time.

It all begs the question: Is it effective or even realistic to expect patients to help enforce hand washing compliance?

Patient and family participation is difficult to accomplish when the culture of a health care organization doesn’t openly encourage and support it, Dr. Shaw wrote. “I think it comes down to creating a new norm where healthcare workers clearly give permission to patients to expect and demand hand hygiene be part of care each and every time. This means focusing on the culture, behaviours  and attitudes of us as healthcare providers.”

There’s an even larger issue here, though, and it’s this: Should hand hygiene be a shared responsibility between patients and clinicians, or does it rest first and foremost with the health care professionals?

Dr. Shaw reflects: “What I learned from my experience is that is the responsibility of the care provider and the healthcare system to do the right thing every time for every patient without expecting patients to be the inspectors of our work.”

Perhaps we shouldn’t be asking how to make it easier for patients and families to speak up and remind clinicians to wash their hands. Perhaps we should be asking instead how to get clinicians to wash their hands every time without needing to be reminded by patients.

Reflections on hand washing

We’ve all heard it a million times: Wash your hands.

Time for dinner? Wash your hands before you sit down at the table. Been playing with the dog? Wash those hands. Is someone in the household ill? Wash your hands, and do it often.

Despite the many technological advances in health care, we have yet to improve on the simple, low-tech effectiveness of soap, water and vigorous scrubbing of the hands – or, as it’s known in the health care world, “hand hygiene.”

The importance of clean hands has been reinforced in recent weeks as influenza, norovirus and the common cold make the rounds. One of the ways each of these viruses can be transmitted is, you guessed it, via hand-to-hand or hand-to-surface contact.

Germs might be too small to see but hands often are teeming with them. It’s estimated that the average human hand harbors 150 different species of microorganisms. Most are harmless but some are not. A few years ago I participated in a classroom experiment involving a swab and culture of each person’s hands, and the culture results for one individual contained staphylococcus.

Most of us know these basics, so why do we often skip the hand washing routine? A few years ago the Minnesota Department of Health conducted an observational study of people who used the public restrooms on the Minnesota State Fairgrounds. The findings were interesting: Adults were more likely than youths to wash their hands after using the restroom, and females had a better rate of hand washing than males. Overall, however, the rate of hand washing with soap and water hovered between 30 percent and 75 percent. The worst group? Teenaged boys, of whom only 18 percent were seen washing their hands.

Nor should we assume health care professionals are better than the general public when it comes to hand washing. When an online survey was conducted among facial plastic surgeons to assess how well they knew and practiced hand hygiene, only about half of the respondents were able to correctly identify which products were the best at killing germs. Nearly 60 percent couldn’t correctly identify when hand washing should optimally take place.

The authors, whose work appeared in 2009 in the Archives of Facial Plastic Surgery, concluded: “Adherence to hand hygiene practices is suboptimal among facial plastic surgeons.”

Overall, it’s believed that fewer than half of health care professionals consistently wash their hands according to best practices for preventing the spread of infection. The reasons are probably the same as for the general public: forgetfulness, not enough time, inconvenient location of sinks, lack of soap and paper towels, and perceived low risk.

The advice from the Minnesota Department of Health: Since there’s no way to know what kinds of germs we might be picking up on our hands, the best defense is frequent and thorough hand washing with soap and water.

Here’s how to do it: Wet your hands with clean water. Apply soap. Rub your hands together vigorously and scrub all surfaces, including between your fingers and under your nails. Scrub for 20 seconds (here’s a rule of thumb: 20 seconds is the equivalent of singing the “Happy Birthday” song twice). Rinse with clean water. Dry your hands briskly.

Waterless, alcohol-based hand sanitizers have become increasingly popular. People like them for several reasons: They’re portable, quick and easy to use and are less apt to dry the skin. There are conflicting opinions, though, on whether they’re as effective as old-fashioned soap and water at killing germs. Some of the research has found that hand sanitizers containing less than 60 percent alcohol don’t work as well. They also seem to be less effective in real-world conditions than the 99.9 percent success rate that many manufacturers claim.

Whether you prefer hand sanitizer or rely on soap and water makes little difference, however, if you’re lax about hand washing in the first place.

Wash your hands!

Photo: Wikimedia Com