Why are hospital patients the critical control point for doctor handwashing?

People in the hospital are invariably immunocompromised. They shouldn’t be fed things like deli meats that may harbor Listeria.

jon.stewart.handwashing.2002And it shouldn’t be the patient’s responsibility to ask if their doctor or nurse washed their hands.

A February audit shows more than 40 per cent of health-care workers and support staff at hospitals in the Regina area (that’s in Canada) failed to wash their hands properly. 

A follow-up report in June also reveals that 67 per cent of 204 doctors observed didn’t follow regional handwashing rules before patient contact. 

Regina Qu’Appelle Health Region (RQHR) requires all staff to wash their hands with soapy water or alcohol-based gels for a minimum of 20 seconds before and after contact with patients. They’re not allowed to wear excessive jewellery on their hands or wrists and can’t have gel nails. 

Kateri Singer, the woman in charge of infection prevention for RQHR said the region’s goal is 100 per cent compliance with handwashing rules “because it is the single most important thing we can do as health-care workers.” 

CBC’s iTeam has combed through RQHR’s February and June reports and has highlighted some of the least compliant facilities. The following percentages indicate non-compliance rates:

Broadview Union Hospital (February) – 94.8%​

Grenfell Health Centre (June) – 77.4%

Regina Lutheran Home (June) – 77.8%​

Wolseley Memorial Hospital (June) – 66.7%

Regina General Hospital – Day Surgery (February) – 86.7%

Regina General Hospital – Labour and Birth (June) – 94%

Pasqua Hospital – Day Surgery (February) – 100%

Pasqual Hospital – Short Stay (February) – 95.2%

Pasqua Hospital – Operating Room (February) – 68%

Pasqual Hospital – 3A (June) – 97%

Transparency is a key to change

handwashing.junk.apr.13Singer said though these numbers look bad, she’s committed to disclosure because “the public has the right to know” whether or not their doctor or nurse is keeping their hands clean. And she said patients have the right to hold them to account.

RQHR seems to have taken the lead in Saskatchewan when it comes to transparency regarding handwashing practices. Its public reports are far more comprehensive than any other region in the province.

Singer said transparency can be a catalyst to change behavior.

Michael Gardam, director of infection, prevention and control at Toronto’s University Health Network, told CBC Saskatchewan’s Morning Edition host Sheila Coles patients often do not feel they can stand up for themselves.

“I have seen patients get screamed at by health care providers,” Gardam said. “I’ve seen patients be told, ‘Don’t come back to my clinic. How dare you challenge me.'”

Are the sick and dying really the critical control point for disease transmission in a hospital?

Maureen Dowd of the New York Times wrote last week about how her brother went into the hospital with pneumonia, quickly contracted four other infections in the intensive care unit, and sadly, died.

Anguished, I asked a young doctor why this was happening. Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother’s hospital gown.

“It could be anything,” he said. “It could be my tie spreading germs.”

I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds.

A couple years later, I read reports about how neckties and lab coats worn by doctors and clinical workers were suspected as carriers of deadly germs. Infections kill 100,000 patients in hospitals and other clinics in the U.S. every year.

A 2004 study of New York City doctors and clinicians discovered that their ties were contagious with at least one type of infectious microbe. Four years ago, the British National health system initiated a “bare below the elbow” dress code barring ties, lab coats, jewelry on the hands and wrists, and long fingernails.

The Centers for Disease Control and Prevention says that health care workers, even doctors and nurses, have a “poor” record of obeying hand-washing rules.

A report in the April issue of Health Affairs indicated that one out of every three people suffer a mistake during a hospital stay.

Commenting on the new report on hospital errors, CNN’s senior medical correspondent, Elizabeth Cohen, instructed viewers to “ask doctors and nurses to wash their hands” if they haven’t.

“They sometimes will actually give you a hard time, believe it or not,” she said, “and they say, ‘My gloves are on. I’m clean.’ ‘Well, I didn’t see you put those gloves on. What if you put those on with dirty hands?’ ”

I called Cohen, the author of “The Empowered Patient,” to ask her the best way to confront those taking care of you or family members. She said that you have to get over the “waiter spitting in your soup scenario,” that the medical professionals will somehow avenge themselves, by giving less attention, if you insult them.

Dr. Peter Pronovost of Johns Hopkins has been able to prove in a national program that you can curb infections and reduce mortality rates in I.C.U.’s by adhering to checklists, creating accountability and fostering a culture where patients, their families and even nurses and residents feel freer to challenge doctors.

We’ve had some success using a mixture of shock and shame – shock being gross photos, shame being social embarrassment – in hospital, teaching and food service environments.

Yesterday, several letter writers voiced their views.

Steven Kussin, a gastroenterologist, is the author of the forthcoming book “Doctor, Your Patient Will See You Now” wrote that asking, “Did you wash your hands?” is not the way to start off the conversation. Doctors or staff members who respond “no” are guilty of a grave medical lapse. If they didn’t wash and then lie to you, they’re also guilty of a grave ethical lapse. Either way, the question raises their defenses and their hackles. Instead, if you didn’t witness a hand-washing ritual, then assume it didn’t happen. You’ll probably be right. Physician hand-washing compliance runs about 33 percent.

When they, or anyone, approach your bedside, give them notice of your intent. Hold out a bottle of sanitizer with a big smile. As you squirt them say: “I know how busy you are, and I am sure you’ve already done this a million times a day. But I’m terrified of those infections I’ve been reading about. I hope you’re O.K. with this.”

Theresa Merrill Anovick of Ridgewood, N.J.,writes, “I send back food in restaurants all the time, and never let a doctor shake my hand until I see him wash his in front of me! Do I get a lot of attitude and resistance? Absolutely. That’s O.K.; then I know that this is not the doctor I want caring for me.”

But is it really up to the sick and dying to enforce basic sanitation?

Doctors, nurses don’t want patients to bug them about handwashing

Consumers are increasingly viewed as the critical control point (CCP) for food and hygiene safety, and are increasingly required to tell others exactly what they think, such as, Dude, wash your hands, Dude, use a thermometer to make sure my burger is done, and Dude, get that finger out of your ear, you don’t know where that finger’s been (or where it’s going).

Dr. Yves Longtin of the Geneva University Hospital presented results of an online survey at the 50th Interscience Conference on Antimicrobial Agents and Chemotherapy in Boston. The 277 respondents — all randomly selected doctors and nurses — believed that patient collaboration could help prevent medical errors, two-thirds had "negative feelings" about such participation programs.

Forty-three percent said that they would "feel humiliated" if they had to admit poor hand hygiene habits. Another 30 percent of workers said they simply would not appreciate patient reminders. Some respondents (16 percent) felt that if patients were to get involved, accountability then would shift partially from the caregivers to those patients.

What’s more, more than one-third of respondents said they would refuse to wear badges encouraging patients to ask about hand washing habits.

"Respondents had a pretty high impression of their own perceived levels of hand hygiene," Longtin said. "However, most believed they could improve."

Handwashing at hospital in Ireland gets worse, not better

With all the attention being paid to handwashing, especially in hospitals, it’s unique when compliance rates get worse rather than better (unless the evaluation techniques are becoming more rigorous).

The Irish Examiner reports an independent hygiene audit of a Dublin hospital has found a drop in standards since it was last assessed two years ago.

The unannounced inspection of the Royal Victoria Eye and Ear Hospital by health watchdog, the Health Information and Quality Authority (HIQA), concluded it had "not maintained its level of performance in relation to the delivery of hygiene services" since it was inspected in 2008.

* Bathrooms/washrooms were visibly unclean in three areas visited (out-patients and emergency departments share these facilities).

* Patients’ personal items were observed in bathrooms/washrooms in one of the areas visited.

* While overall, ward kitchen areas visited were clean, separate hand-wash sinks were not compliant with best practice and in one kitchen no soap was available.

* Clinical waste was stored centrally in a locked unit at the rear of the hospital, however, hazard notices were only observed on one of the locked doors and special hazardous clinical waste was not segregated from this waste.

* Waste destruction documentation was incomplete and the organisation did not demonstrate a consistent approach for monitoring this documentation.

* The majority of handwash sinks in the areas visited did not comply with guidelines for hand hygiene and hand-washing technique — essential for infection control — did not always comply with best practice.