Image: Daylnn Morales, hand hygiene
Sol Neelman  /  special to msnbc
Dalynn Morales, 33, cuddles her son, Xzavyer Newton, at Providence St. Vincent Medical Center in Portland, Ore. Morales, who has leukemia, must be viligant about infections. When a nurse at the hospital tried to adjust an IV without washing her hands, Morales asked her to scrub.
By JoNel Aleccia Health writer
msnbc.com
updated 1/25/2008 7:31:36 AM ET 2008-01-25T12:31:36

It’s a question no hospital patient should have to ask: “Hey, doc, did you wash your hands?”

But in an era of rising rates of drug-resistant infections and overburdened medical staffs, hygiene experts say the best-protected patients are those willing to take safety into their own hands — by asking health workers to wash theirs.

Doctors, nurses and other hospital staffer too busy, too distracted — or, sometimes, too arrogant — to wash up are the target of a growing movement aimed at cutting rates of hospital-acquired infections that kill nearly 100,000 people in the U.S. each year, according to federal estimates.

“Most patients assume health-care workers clean their hands, and they’d be surprised,” said Dr. John Boyce, director of the Hand Hygiene Resource Center at the Hospital of St. Raphael in New Haven, Conn., and a co-author of hygiene guidelines for the federal Centers for Disease Control and Prevention.

At best, hospital staffers wash adequately about half the time, repeated studies show. And some hospitals post hand hygiene rates as low as 20 percent when they start tracking the problem, said Maryanne McGuckin, a former University of Pennsylvania public health researcher who has spent her career trying to boost hand hygiene in hospitals and other health-care settings.

“This isn’t magic. It’s very clear what you need to do,” McGuckin said.

In hundreds of hospitals across the country, patients are being urged to speak up when workers fail to scrub. Posters in patient rooms, tray-top cards, brochures, buttons and direct invitations from staff all deliver the same reminder: “It’s OK to ask.”

That's exactly what Dalynn Morales did. The 33-year-old cancer patient at Providence St. Vincent Medical Center in Portland, Ore., noticed that a nurse failed to clean her hands before adjusting Morales’ antibiotic line.

“I said, ‘Could you please wash?’” Morales recalled, adding that the nurse quickly complied. “I’m not sure if she felt insulted or not.”

For nearly a decade, federal health agencies and researchers have been warning of the connection between health-care hand hygiene and infection. One of the nation’s largest providers, Kaiser Permanente, launched an intensive hygiene program in 2001. But with the recent surge in dangerous, even deadly, infections such as Methicillin-resistant Staphylococcus aureus, the stakes are higher.

“We’re now making the association that people are dying of MRSA because people aren’t washing their hands,” said McGuckin.

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Workers’ reasons for not washing range from simple forgetfulness to being too busy to pause between patients. Others rely on gloves, forgetting that they need to scrub before donning them. And a few doctors and other health workers seem to believe they’re immune to basic rules of sanitation.

National guidelines say they’re supposed to use alcohol-based hand rubs or soap and warm water for at least 15 seconds before and after every direct contact with a patient, with excretions, or with contaminated surfaces or objects. Too often, however, they don’t.

“It’s an ever-present conundrum,” said Diane Waldo, director of quality and clinical services with the Oregon Association of Hospitals and Health Systems, which recently launched a hand hygiene program, one of several in the nation.  “Everybody learns it and understands it, but compliance and accountability are another thing.”

There’s no question that improved hand hygiene reduces hospital infections, said Boyce. It’s a fact doctors have known since 1846, when Vienna’s Dr. Ignaz Semmelweis halted patient deaths by directing his medical students to wash up between the pathology lab and the maternity ward. 

Recent research has reiterated the connection, including an August study in the journal Pediatrics that showed that boosting hygiene rates cut hospital-acquired infections by 60 percent in more than 1,000 tiny newborns at a children’s hospital in Switzerland.

Even in that study, however, hygiene compliance rose only from 42 percent to 55 percent, the authors said.

For Morales, the Portland patient who piped up, the idea that hospital workers wash their hands only about half the time is astounding.

“That’s something you just expect a doctor or a nurse to do,” said Morales, who learned she had leukemia after delivering her fourth child this month.

Will they be offended?
It never would have occurred to her to ask a hospital worker to wash, but St. Vincent’s officials who joined a state hospital hand hygiene project last summer made it clear with pamphlets, posters and personal invitations that Morales should feel free to speak up.

Overcoming fears of insulting staff can be a chief challenge, especially among elderly patients, said Dr. Woodruff English, the epidemiologist at St. Vincent’s.

“It’s a generational thing. We all have our cultural values and the older population is generally respectful of rules and authority,” he said.

McGuckin's research shows that 80 percent of patients will speak up if they’re invited, and that when they do, hygiene can improve by as much as 56 percent within weeks. How health-care workers react when they’re reminded about hand hygiene is crucial.

When Kaiser Permanente, one of the nation’s largest health-care providers, started a hand hygiene program in 2001, some staff members, especially doctors, resented the effort, noted Dr. Steve Parodi, the agency’s infectious disease chief and Sue Barnes, a registered nurse and national safety manager.

“There was some sense of reluctance on the part of physicians at having patients tell them what to do,” Barnes said.

Compliance rates rise
The alarming rise of drug-resistant infections has changed such views. At the St. Louis Children’s hospital, 2,500 employees wear buttons that say “Ask me!” and participate in activities like a monthly “Hand Hygiene Hoopla” that includes games and treats, said Susan Hibbits, the hospital’s director. In Portland, staff members have been instructed to respond with a smile and a “thank you” when patients remind them to wash their hands.

At Kaiser, the company reported that hand hygiene compliance rates rose from about 53 percent to 79 percent within three years of starting the program. In St. Louis, compliance rose from 59 percent in 2004 to 96 percent in 2007, officials said.

Verifying such improvement is difficult, however, because there’s no shared standard, said Dr. Robert Wise, vice president of standards and survey methods for the Joint Commission, a national hospital accrediting agency. Some hospitals rely on direct observation, either by staff members or independent consultants, but those results can be tainted by personal bias or practical problems.

McGuckin runs a private firm that charges hospitals to track hand hygiene by measuring the amount of soap and sanitizer care units use over time. But that method can’t exactly tell who’s washing — or when.

“While there are a lot of ways to intervene, there aren’t a lot of ways to measure compliance,” noted Wise.

The commission has been tackling hand hygiene in conjunction with the World Health Organization. This spring, it plans to publish a report on the most effective methods for measuring hospital hygiene.

Meanwhile, urging patients to monitor their health-care workers is only one of several ways to improve hygiene, said Boyce, who's a national expert on the subject. More research will be necessary to determine not only the best way to measure hygiene, but also the best interventions.

"Having a multi-disciplinary program to promote hand hygiene is important," Boyce said.

Now that infections such as MRSA have become household worries, perhaps people will actually listen, Wise added.

“That the public catching up with this, we view that as a good thing,” he said. 

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