The keynote address of a mother's story at the annual Solutions for Patient Safety Spring National Learning Session1 highlighted the tragic impact of 3 hospital-acquired conditions (HACs) on a 4-year-old little boy and his family-reminding attendees that HACs are more than mere numbers or control charts but rather they affect human lives. This mother highlighted the opportunities for better and more consistent hand hygiene than what she observed during her child's hospitalizations, and how better hand washing might have helped save her child's life. Many of us have similar stories within our own organizations and neonatal intensive care units (NICUs). Hospitals across the country continue to work on reducing preventable harm, focusing on getting to zero. Since the To Err Is Human2 report in 1999, hospitals have had significant reduction in infection; even so, more work is still needed. Reducing HACs, such as central line-associated blood stream infections (CLABSIs), is a global health initiative.3 While many centers have significantly reduced their CLABSI rates over the past few years, consistent and sustainable reduction is difficult to achieve. Central lines are necessary for many infants in the NICU, and insertion and maintenance of these lines require consistent meticulous care. CLABSI prevention is vital, yet not straightforward, due to the complexity of the environment and the biology of the neonate. While many NICUs continue to apply and monitor CLABSI prevention bundles and evidence-based strategies, reduce the number of central lines days, implement standard prepackaged central line kits, and reduce line entries, it may be possible that something as simple as basic hand hygiene is being overlooked.
Hand hygiene has reemerged as a top priority due to the emerging multidrug-resistant organisms (MDROs) and invasive candidiasis, caused by the use of broad-spectrum antibiotics for unproven infections, including the most recent strain of yeast-Candida auris.4Candida auris has caused severe illness in hospitalized patients worldwide and, more recently, has been identified within the United States. The alarming attributes of some strains of Candida auris include their resistance to all 3 major classes of antifungal agents and their ability to persist on surfaces and spread between patients, unlike most other Candida species. Hand hygiene and environmental cleanliness are effective foundational strategies to limit the spread of MDROs.
HISTORY OF HAND HYGIENE AND COMPLIANCE BARRIERS
It has been nearly 2 centuries since Ignaz Semmelweis and Florence Nightingale demonstrated the link between hand washing and improved health outcomes.5 Since then, hand hygiene is known to be the single most important intervention to reduce transmission of pathogens in healthcare settings. Yet, despite the clear benefits of hand hygiene, far too often it is not a priority, possibly due to staff workload, inconvenience of cleaning product location (eg, dispensers or sinks), skin irritation from cleaning product, emergency situations, lack of accountability among healthcare workers, or interruptions/distractions of busy clinicians who may otherwise forget.6 Having systems in place to support, monitor, measure, and promote correct behavior is vital to demonstrating improvements and reducing hospital-acquired infections. The World Health Organization7,8 (WHO) estimates that healthcare providers spend less than half the amount of recommended cleaning time for their hands. Therefore, the WHO Global Patient Safety Challenge7 focused on hand hygiene, recognizing that measuring hand hygiene compliance among healthcare providers is not simple and operational definitions and fundamental guidance are vital to changing practice. Yet, more than a decade later, organizations continue to work on improving hand hygiene compliance rates, demonstrating the continued complexity and that a one-size-fits-all approach is not effective if organizations do not take the time to understand why hand hygiene is failing.
One significant barrier to sustaining reliable hand hygiene compliance is the assumption that all healthcare workers know when to clean their hands. Healthcare workers who come in contact with a patient or the patient's environment are expected to perform hand hygiene multiple times throughout the encounter. The WHO guidelines recommend 5 indications, or 5 moments, for hand hygiene.8,9 The 5 moments for hand hygiene illustrate when to clean hands: before patient contact, before aseptic task, after body fluid exposure (eg, Foley catheter), after patient contact, and after contact with patient surroundings (eg, bedside table, monitor, cell phone). It is important to understand that hand hygiene is more than just washing or foaming hands before and after entering a patient room.
CULTURE AND HAND HYGIENE COMPLIANCE
Hand hygiene compliance can be related to unit or organizational culture of safety. Leadership must commit to hand hygiene as an organizational priority and demonstrate support by role modeling, prioritizing, providing resources, and establishing clear expectations. Hand hygiene is vital for all staff members regardless of role, and the staff should be encouraged and feel safe to speak up and remind others to wash their hands. Creating a positive culture that is supportive and encourages the staff to be actively involved in holding one another accountable with in the moment coaching and honest feedback, rather than blaming or punitive, is a critical component of hand hygiene promotion. The focus on reminding others to wash their hands should be centered on what is best for the patient. Partnering with families in their child's care and encouraging them to speak up to other members of their family, other healthcare team members, or the staff who enter their child's room without performing hand hygiene will help promote and spread a culture of safety. Both nursing and medical leaders can help shape a positive, safe-to-speak-up culture in which neither parents nor staff fear reprisal.
As we focus on global health, let us challenge ourselves with how we can consistently and reliably perform the 5 moments of hand hygiene to keep our patients safe and to prevent another avoidable death of a young child.
-Joan R. Smith, PhD, RN, NNP-BC
Director
Clinical Quality, Safety & Practice Excellence
St. Louis Children's Hospital
St. Louis, Missouri
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