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

As suggested by some studies, physician hand-hygiene compliance has an impact on peer and group behaviors (25,28). A recent evaluation of learned physician behaviors found that only 8.5% medical student candidates washed after patient contact (28). Since medical students may someday be influencing future hand-hygiene compliance behaviors of other health-care workers, the importance of hand hygiene should be incorporated into the medical school curriculum.

Our observations also suggest that health-care worker hand-hygiene compliance may improve when health-care providers perceive risk for their own health. In particular, hand hygiene before patient contact in our study was significantly worse than hand hygiene after patient contact. Whereas patients may be protected from acquisition of pathogenic organisms if health-care workers perform hand hygiene before patient contact, health-care workers may perceive a risk to themselves after patient contact; they respond by washing their hands. In addition, health-care workers were more likely to perform hand hygiene after an invasive procedure, which does not benefit the individual patient, but rather the health-care worker, who may be concerned about acquiring a pathogen present in body fluids. Finally, glove use could be a marker for hand-hygiene compliance if health-care workers are concerned about the personal risk from transmission of pathogens, and thus are more likely to wear gloves and cleanse their hands.

The hand-hygiene compliance we observed (finding that nearly 50% of our workers washed their hands after patient contact) was similar to the frequency of hand-hygiene compliance reported by other investigators (5,7,10-12). Even though we saw no improvement, our baseline rate was comparable to that of a recent report by Bischoff and associates after they improved hand hygiene compliance by using accessible alcohol-based antiseptics and increased hand-hygiene compliance (41% to 48%) after patient contact (5).

While some studies (5,15), and health-care worker surveys (29) suggest that sink access is an important determinant of hand-hygiene compliance, we found access is not the sole requirement needed to increase hand-hygiene compliance. Few reports address the impact of hospital design on hand-hygiene compliance. Kaplan and McGuckin (15) compared two units and demonstrated a greater hand-hygiene frequency among nurses in an MICU having a 1:1 sink-to-bed ratio compared with an SICU having a 4:1 sink-to-bed ratio (76% vs. 51%; p<0.01). However, a study by Preston and colleagues evaluating hand hygiene after the number of sinks in an ICU was increased found that improved sink access had no effect on hand-hygiene frequency (26). Possible explanations for the decreased hand-hygiene compliance we observed include: 1) more patient-days (5.2%) and more admissions (11.7%) per month occurred for study period II compared to study period I; 2) disrupted work flow because of the new and unfamiliar environment of the new hospital; 3) removal of hallway sinks; and 4) addition of new or temporary nursing staff because of the increased number of patients. Patient:nurse ratios are considered an important determinant in hand-hygiene compliance (6). In our study, we believe the ratios were similar in the old and new hospitals, but these data were only formally available for the ICUs. The average patient:nurse ratio during the observation periods in the new MICU was 1.42 (standard deviation [SD] 0.15) and in the old MICU, the ratio was 1.43 (SD = 0.05). We found similar data in the SICU areas, where average patient:nurse ratio during our observation periods in the new unit was 1.03 (SD = 0.24); in the old unit, the ratio was 1.22 (SD = 0.14). Thus, the ICU staffing patient:nurse ratio was similar during the observation shift for the ICUs in the old and new hospitals (p [greater than or equal to] 0.2).