Influence of role models and hospital design on hand hygiene of health care workers - Research

Emerging Infectious Diseases, Feb, 2003 by Mary G. Lankford, Teresa R. Zembower, William E. Trick, Donna M. Hacek, Gary A. Noskin, Lance R. Peterson

We assessed the effect of medical staff role models and the number of health-care worker sinks on hand-hygiene compliance before and after construction of a new hospital designed for increased access to handwashing sinks. We observed health-care worker hand hygiene in four nursing units that provided similar patient care in both the old and new hospitals: medical and surgical intensive care, hematology/oncology, and solid organ transplant units. Of 721 hand-hygiene opportunities, 304 (42%) were observed in the old hospital and 417 (58%) in the new hospital. Hand-hygiene compliance was significantly better in the old hospital (161/304; 53%) compared to the new hospital (97/417; 23.3%) (p<0.001). Health-care workers in a room with a senior (e.g., higher ranking) medical staff person or peer who did not wash hands were significantly less likely to wash their own hands (odds ratio 0.2; confidence interval 0.1 to 0.5); p<0.001). Our results suggest that health-care worker hand-hygiene compliance is influenced significantly by the behavior of other health-care workers. An increased number of hand-washing sinks, as a sole measure, did not increase hand-hygiene compliance.

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One of the key components for limiting spread of healthcare--associated infectious disease is adequate infection control practice. A cornerstone of infection control is ensuring that health-care workers wash their hands at appropriate times. The Association for Professionals in Infection Control and Epidemiology (APIC), the Guidelines for Handwashing and Hospital Environmental Control (1985, 2001) from the Centers for Disease Control and Prevention (CDC), and the Hospital Infection Control Practices Advisory Committee each highlight specific indications for handwashing compliance (1-4). Although CDC guidelines state that handwashing is the single most important procedure to prevent nosocomial infection (2,4), studies continue to report unacceptable health-care worker hand-hygiene compliance rates (5-12). Efforts to improve hand-hygiene behavior that have focused on broad-based educational and motivational programs have had minimal sustained success (11-14).

Factors perceived as contributing to poor hand-hygiene compliance include unavailability of handwashing sinks, time required to perform hand hygiene, patient's condition, effect of hand-hygiene products on the skin, and inadequate knowledge of the guidelines (10,15-21). In addition, some reports suggest that role models, group behavior, and the level of managerial support influence reported levels of compliance (17,21-24). One measure recommended to improve the hand-hygiene rate is enhanced access to hand-hygiene facilities (15-17,25). However, few studies have prospectively evaluated the association between hand-hygiene compliance and building design (16,26). We assessed the effect of medical staff role models and the number of health-care worker sinks on hand-hygiene compliance before and after construction of a new hospital designed for increased access to handwashing sinks. We also evaluated whether the frequency of health-care worker hand hygiene was influenced by the behavior of senior medical-care providers.

Methods

Setting and Study Participants

The old hospital had 683 private and semi-private rooms. Observations were made in the 33-bed hematology/oncology unit, the 23-bed solid organ transplant unit, the 16-bed surgical intensive-care unit (SICU), and the 11-bed medical intensive-care unit (MICU). Sink-to-bed ratios in the units were 8:33 in the hematology/oncology unit, 4:23 in the solid organ transplant unit, and 1:1 in both ICUs.

Sinks were located in various sites in the old hospital. The non-ICUs had a limited number of handwashing sinks for health-care worker use located on walls in the middle of each hallway, in clean storage rooms, and in soiled-linens utility rooms. The hematology/oncology unit had a single handwashing sink located in each of three hallways, two handwashing sinks located in each corridor for the bone marrow transplant patient rooms, and a handwashing sink in the anteroom to the bone marrow transplant suite. The solid organ transplant unit had a single handwashing sink located in each of two hallways. ICUs had private rooms with a sink located inside the entrance of every patient room but no hallway sinks.

The new hospital opened with 492 individual (private) patient rooms. Observations in the new facility were done in the 30-bed hematology unit, the 30-bed oncology unit, 30-bed solid organ transplant unit, the 12-bed SICU, and the 17-bed MICU. A sink dedicated for hospital personnel use is located inside every patient room. No sinks are available in the hallways.

Hand-Hygiene Definition

We defined hand hygiene as any duration of washing with soap and water. No waterless alternatives were available for other types of hand hygiene during the study. We recorded hand-hygiene compliance on room entry and after each hand-hygiene opportunity. The definitions of hand-hygiene opportunities, patient contact, and invasive procedures used for this analysis are consistent with APIC or CDC guidelines (Table 1). Inanimate objects considered likely to be contaminated included endotracheal tubes, suction equipment, urinary collection devices, rectal tubes, thermometers, bed linens, and biohazardous waste containers.