Checklist culture to reduce risk

Tina Rosenberg of the New York Times follows up her ‘machines that go ping’ piece about hi-tech handwashing compliance techniques with a low-tech approach that seems ridiculously successful: checklists.

“In 2003, the Michigan Health and Hospital Association began an experiment to see if its members could bring down the rate of infection in central line catheters — one of the deadliest types of hospital-acquired infections.

“The intensive care units at nearly every hospital in Michigan participated — 103 I.C.U.’s. What they had to do was use a five-point checklist to prevent infection when inserting the catheters. The steps were: Wash hands. Cover the patient with sterile drapes. Clean the skin with chlorhexidine antiseptic. Do not insert catheters into the groin area. Remove catheters as soon as they are no longer needed.

“A paper in the New England Journal of Medicine by Peter Pronovost, the Johns Hopkins University doctor who designed the checklist, set out the results.

“’Within 3 months after implementation, the median rate of infection was 0, a rate sustained throughout the remaining 15 months of follow-up. All types of participating hospitals realized a similar improvement.’”

“Atul Gawande wrote about the checklist in The New Yorker, and went on to write a book called “The Checklist Manifesto.” In his article, he talks about how the checklist makes each step explicit and helps harried doctors and nurses to remember all of them. …

“The checklist itself probably isn’t useful for routine hand-washing — there would be only one item on it. What is useful is borrowing the way the checklist replaces a culture of “no questions” with a culture of “patient safety comes first and it is part of my job to speak up.”

“One very valuable source for ways to improve hand-washing rates comes from the health care industry’s Joint Commission Center for Transforming Healthcare Hand Hygiene Project. The project worked with eight hospitals to implement pilot programs designed to raise hand-washing rates in different ways. A solution that helped almost everywhere was to streamline workflow to make it easier and more automatic to wash hands: for example, to put sinks in the same place in every room, with a table to put down items the nurse might be carrying. Keep supplies in every room so nurses don’t have to go in and out to get them.

But the project also found, as many readers suggested, that hospital managers needed to elevate hand-washing as a priority, stress its importance, and hold all hospital workers accountable. Accountability requires knowing the hand-washing rates of different units and people, which is why the technological systems I wrote about on Tuesday can be important. But data only matters if it is used. Once hospitals can know their workers’ hand-washing rates, they need to use the information for coaching and to create incentives — both negative and positive.”

Proper handwashing requires proper tools; no preaching without provisions

A Toronto school had 250 students absent with flu-like symptoms earlier this week, believed to be norovirus-related. A school in Philipsburgh, PA, was closed today after 100 kids developed what was thought to be norovirus. And the tri-delts at the University of Michigan were barfing a couple of weeks ago because of, norovirus.

These stories all carry advice for students to wash their hands. But have any of these intrepid reporters gone to the school or sorority and checked out whether proper tools – running water, soap, paper towel – were available for proper handwashing? Too frequently, such tools are glaringly absent, especially in schools.

Obama says – dude, wash hands to contain swine flu

When asked about swine flu – oh, sorry, the H1N1 flu – U.S. President Barack Obama said during his prime-time 100-day press commencement conference that handwashing and staying at home if sick were key to controlling any potential spread of flu.

As we’ve said, proper handwashing with the proper tools — soap, water and paper towel — can significantly reduce the number of foodborne and other illnesses, even the emerging swine flu.

The steps in proper handwashing, as concluded from the preponderance of available evidence, are:

• wet hands with vigorously flowing water;

• use enough soap to build a good lather;

• scrub hands vigorously, creating friction and reaching all areas of the fingers and hands for at least 10 seconds to loosen pathogens on the fingers and hands;

• rinse hands with thorough amounts of water while continuing to rub hands; and

• dry hands vigorously with paper towel.

If any of the tools for handwashing are missing, let someone know.

However, even with reminders and access to the proper tools, not everyone will practice good hygiene. Those signs that say, ‘Employees Must Wash Hands’ don’t always work. We’re working in settings like high schools and hospitals to figure out the best way to not only tell people to wash their hands, but to use new media and messages to really compel individuals to wash their hands.

A video is available at:

and a poster at

Time to survey toilets

The Western Mail in Wales reports the National Assembly’s Enterprise and Learning Committee has found education funding is so complicated schools are missing out on vital cash for basic facilities like clean toilets and classrooms as a result.

It is calling on the Education Minister Jane Hutt to lift the “funding fog”, and also wants the Assembly Government to carry out an immediate survey of all school toilets.

Sharon Mills, of Deri, near Bargoed, whose five-year-old son Mason died after contracting E. coli, said,

"We are living in the 21st century, yet many school toilets are like something from the dark ages."

Although it is believed the Deri Primary School pupil contracted the food poisoning bug through infected meat, many of the 150 people – most of them school children – who were struck down two years ago contracted the illness from people who were already infected. Promoting good handwashing habits is seen as one of the best ways of preventing disease.

But an inquiry by leading Welsh health experts found that a failure by many schools to provide basics such as warm water and soap for children to wash their hands after using the toilet encouraged the bug to spread.

Mother-of-two Pam Sacchi, of Bridgend, whose son Daniel, now 14, was hospitalised after contracting E.coli in 2005 when he was 12, said:

“I still have parents coming up to me, complaining their children don’t have soap to wash their hands with in their school toilets. This should not be happening and something needs to be done. I realise there are sometimes funding shortfalls but the health of our children must come first.”

Proper handwashing begins with access to proper tools. That is why soap and paper towels are a necessary requirement for any public bathroom.

Proper handwashing still requires proper tools

It’s a message that goes unheeded — at home and abroad.

Research published in the New Zealand Medical Journal found almost 20 percent of men, and 8 percent of women didn’t wash their hands after going to the toilet.

But what’s worse says New Zealand Public Health Association (PHA) Director Dr Gay Keating is that some schools have appalling washroom facilities, and it is often not possible for students to wash and dry their hands properly – even if they want to.

"Sometimes there is no soap, let alone hot water, and children are expected to wash their hands in freezing water, even in the middle of winter. There may be no paper towels, or hand dryers.

"This is a great disincentive to proper hand washing, and pupils who do not wash their hands properly are at greater risk of contracting illnesses themselves, or passing on bugs. They then have to have days off school, which recent educational research has shown often leads to them falling behind in school work. …

“Hand-hygiene is basic to maintaining good health.”

Dr Keating says all schools should provide pupils with soap, warm water and hand-drying facilities.