EVERY YEAR, nearly 2 million Americans acquire infections in hospitals, and an estimated 90,000 die as a result, according to the Centers for Disease Control and Prevention (CDC).1 These largely preventable infections occur despite the efforts of well-intentioned healthcare professionals, advances in technology, and widely accepted standards of practice. Infections common to all settings include catheter-associated urinary tract infections, bloodstream infections (usually associated with intravascular devices), and pneumonia. Surgical-site infections are also a challenge for ambulatory care and acute care providers, while home-care and long-term care professionals often deal with skin and soft tissue infections.
The causes of healthcare-associated infections cannot be dismissed by simply attributing the problem to an increasing number of frail, elderly, or immunocompromised patients in healthcare organizations. Instead, healthcare professionals must look to evidence-based guidelines to prevent this significant threat to patients.
NATIONAL PATIENT SAFETY GOAL FOCUSES ON INFECTION CONTROL
According to an infection control expert at the CDC, clean hands are the single most important factor in preventing the spread of germs and antibiotic resistance in healthcare settings.2 Others have suggested that hospitals could save upward of 10,000 lives per year if they imposed a zero-tolerance policy for workers failing to wash their hands.3 Poor hand hygiene is not, however, a matter of staff willfully putting patients at risk. A lack of consciousness about the impact of hand hygiene and time pressures, along with organizational issues such as inadequate staffing, combine to create an environment in which an average of only 40% of workers comply with good hand-hygiene practices.4
To address the issue of healthcare-associated infections, the Joint Commission on Accreditation of Healthcare Organizations has in recent years further strengthened its infection control standards and established a National Patient Safety Goal specifically related to the issue (see Box 1). National Patient Safety Goal 7 requires organizations to "reduce the risk of healthcare-associated infections." One of the 2 associated requirements for this goal calls for organizations to comply with current CDC hand-hygiene guidelines.
The CDC guidelines, released in 2002, advise the use of alcohol-based hand rubs in addition to soap and water to protect both patients and staff.5 The guidelines provide practical advice for helping healthcare workers remember to practice appropriate hand hygiene, such as making an alcohol-based hand rub available at the entrance to the patient's room or at the bedside, in other convenient locations, and in individual pocket-sized containers to be carried by caregivers. The proper use of sterile gloves is important as well. Bacteria can be spread from one part of the body to another if staff do not replace soiled gloves between tasks. Used gloves should be removed before staff touch surfaces such as door handles or telephones.
The CDC guidelines also address long-standing issues such as healthcare personnel avoiding the use of artificial nails and keeping natural nails less than one quarter of an inch long if they care for patients at high risk of acquiring infections. The full CDC report is available at http://www.cdc.gov/handhygiene/. The specific recommendations referred to in the Goal are on pages 31-34 of the report.
NATIONAL PATIENT SAFETY GOAL COMPLIANCE
To comply with the hand-hygiene recommendations for Goal 7, organizations must adhere to all IA, IB, and IC recommendations from the CDC. The CDC recommendation categories refer to the following:
IA: Strongly recommended and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
IB: Strongly recommended, although only with the support of certain experimental, clinical, or epidemiologic studies and a strong theoretical rationale.
IC: Required by federal or state regulations or standards.
Compliance with Goal 7a is evaluated by Joint Commission surveyors through interviews (ie, the tracer methodology) with nurses and caregiver staff along with direct observation. Nurses and other caregivers should know what is expected of them with regard to hand hygiene and should practice it consistently. It is expected that noncompliance will be quite low so that any pattern of noncompliance, that is, more than a sporadic miss, will be scored as noncompliance. During tracer activity, if surveyors observe 3 or more instances of noncompliance, through either observation of practice or staff interview, a requirement for improvement will result.
To help improve infection control and comply with National Patient Safety Goal 7a, nurse leaders should consider the following strategies.
* Move outside traditional disciplinary boundaries to establish and implement a multidisciplinary program designed to improve adherence to recommended hand-hygiene practices.
* Individually commit to the CDC's hand-hygiene requirements.
* Serve as an example to other nurses and healthcare staff by practicing good hand hygiene.
* Play a role in making improved adherence to hand-hygiene practices an institutional priority and securing necessary leadership and financial support.
* Encourage patients and families to speak up and ask healthcare workers to clean their hands. (See the Joint Commission's Speak Up educational campaign, "Three Things You Can Do to Prevent Infection," http://www.jointcommission.org.)
* Place posters by sinks and in bathrooms to remind staff to wash their hands.
* Monitor hand-hygiene adherence and provide feedback.
* Monitor the volume of alcohol-based hand rub used per 1000 patient days.
In addition, it is important to recognize that staff training that leads to improved hand-hygiene practices is the most effective method for preventing the spread of healthcare-associated infections. Training and orientation for all staff should include infection control and prevention procedures. Nurses and other direct care staff should understand how to identify risk factors for infection in their patient population(s). The elderly are especially vulnerable. Patients with indwelling devices such as catheters and those undergoing invasive therapy such as home infusion, ventilator support, and dialysis are also considered high-risk populations as is anyone undergoing surgery or another invasive procedure. Organizations that make infection control part of the competency assessment program also demonstrate a commitment to improving the quality of care patient and safety by reducing infections.
CONCLUSION
Hand hygiene is the most effective way to prevent the spread of infection. Many nurses and other healthcare workers are embracing the use of alcohol-based hand rubs because they take less time to use than traditional hand washing. The CDC estimates that, in an 8-hour shift, 1 hour of an ICU nurse's time will be saved by using an alcohol-based handrub.5 While compliance with proven hand-hygiene methods presents many challenges for healthcare organizations and professionals, it must be the foundation of all infection control programs. Educating nurses and other staff about the importance of their individual actions and proper hand hygiene can improve patient safety and create an organizational culture that promotes hygiene.
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