Hand Hygiene In Primary Care Clinics

In health care, the majority of infection control processes are designed for the inpatient setting. It is important to review these practices for applicability in outpatient/primary care clinic environments as well. The corner-stone of infection control is basic hand washing. Observational studies done in hospitals from 1981 to 2000 identified a poor compliance, with an overall average of only 40% of health care workers adhering to recommended hand hygiene procedures (Boyce & Pittet, 2002).

In 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established its first annual National Patient Safety Goals (NPSGs) and associated requirements for improving the safety of patient care in health care organizations. These went into effect in 2003. JCAHO requires organizations to demonstrate how they are meeting these NPSGs. Since the beginning, reducing the risk of health case-associated infections has been on this list (JCAHO, 2006a)

In October 2004, JCAHO, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, the Centers for Disease Control and Prevention (CDC), the Infectious Diseases Society of America (IDSA), and the Society for Healthcare Epidemiology of America launched a national campaign to urge Americans to "Speak Up" and take appropriate steps to reduce the spread of infection. One of the key activities identified in the "Speak Up" program was hand hygiene, called "washing hands" (JCAHO, 2006b).

The 2006, NPSGs continue to reflect the responsibility of reducing infections and using proper hand hygiene. The specific Safety Goal related to hand hygiene includes:

* Goal 7: Reduce the risk of health care-associated infections.

* 7A: Comply with current CDC hand hygiene guidelines (JCAHO, 2006c).

JCAHO reviewers routinely question staff about the Hand Hygiene (HH) compliance rates. Additionally, organizations are being asked how their process improvement activities are assuring that hand hygiene rates are being maintained or improved.

Denver Health Community Health Services (DH-CHS) participated in an agency-wide program of documenting, evaluating, maintaining, and where necessary, improving hand hygiene activities. DH-CHS is part of the Denver Health and Hospital Authority, a nationally recognized safety net health care system. DH-CHS is one of the largest federally funded community health centers in the United States. In 2005, DH-CHS provided more than 360,000 preventive and primary care visits to the citizens of Denver through 9 facilities/primary care clinics and 12 school-based clinics, encompassing 22 clinical units. This article will focus on the 8 family medicine clinics.

The Hand Hygiene project in the DH-CHS was organized and conducted by the DH-CHS Infection Control Coordinator. The project began in the second quarter of 2005. The initial step was to identify current HH compliance rates in the clinic environments. A surveillance tool was developed that identified HH compliance prior to and following patient contact.

Self-rating at the DH-CHS sites reported 100% compliance. However, when selected staff observed hand washing at these sites, the hand hygiene compliance rates were found to be much lower (see Figure 1).

Overall, staff observations were made without the clinic staff knowing that their hand washing activities were being watched and recorded. Twenty staff observations were made at each site using the hand hygiene surveillance tool. The disparity between initial self-monitoring and surveillance results could have resulted from several issues. Possible issues identified were lack of staff knowledge relating to the importance of hand hygiene in the prevention of the spread of infection among staff and clients. In addition, there may have been no clear definition of what was expected (for example, each staff observation necessitates hand washing before and after patient contact). The availability of convenient HH products may have also been a factor.

The HH compliance rates among the categories of staff observed were also found to be divergent (see Figure 2).This chart identifies the 4 categories of staff observed for hand washing practice before and after patient contact. The DH-CHS categories of staff include:

* MD - Physician, resident.

* ACP - Advanced care practitioner: Physician assistant, certified nurse midwife, nurse practitioner.

* RN - Registered nurse.

* MA - Medical assistant.

After reviewing the results of these initial observations, an improvement plan was developed, the corner stone being the education process. Data collected in second quarter were identified as the baseline hand hygiene compliance rates. The goal in the improvement plan was not only to achieve 100% HH compliance, but also to encourage the staff to have good HH procedures become "automatic" to them.

The strategy that was developed included the following processes:

* A program of staff education was initiated, utilizing the CDC hand hygiene guidelines. These guidelines include the importance of washing immediately before and immediately after patient contact and the length of time to complete a hand washing, as well as the types of HH products to use (Boyce & Pettit, 2002).