In Get Me Out, Randi Hutter Epstein recounts that in the early 1800s, many women died soon after childbirth from childbed fever, or what we now refer to as puerperal or postpartum infections. All sorts of theories circulated to explain why healthy women became gravely ill and all too often died after delivering their babies. It turned out that they were dying of what we now call healthcare-associated infections. The major source of their infections was the unclean hands of the doctors who cared for them.
At that time, many women who conceived children out of wedlock were prone to abandon or kill their newborns rather than suffer social retribution for bearing an out-of-wedlock baby. To curb this trend, free maternity clinics sprang up across Europe. Supervised medical and midwifery students staffed the clinics, enabling the free clinics to be used as training sites. There were two of these clinics in Vienna—one staffed largely by physicians and medical students, the other staffed by midwives and their trainees. If a woman delivered her baby in one of these clinics, the clinic would cover all medical expenses and arrange for the baby to be adopted.
Women wanted the free care for themselves and their babies but were afraid to deliver their babies in these clinics. So much so that they often preferred to deliver their babies in the dirty streets of Vienna because they were aware that the rate of childbed fever was lower among women who delivered babies in the streets rather than in the clinics. Some went so far as to feign spontaneous delivery right outside the clinic doors to reap the benefits of the free care without having to deliver their babies inside.
Interestingly, the death rate due to childbed fever was much higher in the physician-run clinics than the midwife-run clinics. Dr. Ignaz Semmelweis, a young resident physician, observed women begging to be admitted to the midwife clinic rather than the physician clinic. The women were frightened; Semmelweis was perplexed. What was the difference?
It eventually dawned on Semmelweis that most physicians performed autopsies while the midwives did not. Thus he concluded that the doctors were transferring particles from the cadavers to their obstetric patients.
Noting the dangers apparently associated with being cared for by the physicians, Semmelweis ordered medical students and doctors to wash their hands with a chlorinated lime solution when leaving the autopsy room and before caring for live patients. In very short order, he observed a 90 percent decrease in deaths associated with childbed fever. So, of course, across Europe a successful handwashing campaign took root and millions of lives were saved, right? Au contraire!
Semmelweis’s conclusion that childbed fever was associated with a lack of cleanliness was highly controversial. Many physicians were appalled that he would suggest patient deaths were due to a lack of cleanliness on their part and refused to comply with his handwashing regimen. Although his theory was gaining traction in some communities, he was driven out of Vienna.
While practicing medicine in another city, Semmelweis continued his campaign to promote rigorous handwashing. He began to feel a frantic need to see such change implemented and wrote increasingly angry letters to prominent European obstetricians over the lack of compliance. At one point, he denounced some of his medical colleagues as “irresponsible murderers.” Many of them, and eventually his wife, concluded he was losing his mind.
Semmelweis was then forcibly admitted to an insane asylum where he suffered from severe beatings by guards on duty. Some of his wounds became infected. In a distressing twist of fate, Semmelweis died fourteen days later of a institution-associated infection—just like the women he was trying to save from suffering the same misfortune.8
The Beat Goes On
One hundred fifty years later, the battle rages on. A cadre of impassioned professionals continues to promote handwashing campaigns, resolved to put the knowledge into action with every patient, in every encounter, every time. Among the broader guild of physicians, there remains wide variability for the appreciation of the importance of proper hand hygiene.
Remember, safety training is typically mandatory for the employed hospital staff while remaining optional for physicians who work in the same facilities. As you would expect, physician participation in voluntary safety training is notoriously low. As a consequence, nurses and other staff often observe physician leaders failing to use safety practices that they themselves have been told are critically important. Over time, lack of physician buy-in corrodes employee commitment to behavior change. For many, the expected safety behaviors never become ingrained practices, and any initial gains in this direction are quickly lost.
Even when physician leaders are current on a hospital’s patient safety guidelines, they sometimes inadvertently undermine a culture of safety through their own actions. When they don’t do as expected, the ramifications are compounded. It is the physicians’ behavior the staff tends to emulate—regardless of what policies are in place.
Case in point: during my first month as a patient safety director for a large healthcare system, I experienced the challenge of confronting someone about clean, safe care. According to policy, it was imperative that healthcare professionals wash their hands each and every time they enter and exit the intensive care unit. Making patient safety rounds with a hospital vice president (let’s call her Dr. Drift) taught me an unintended lesson. Dr. Drift snapped when I reminded her to wash her hands upon exiting the intensive care unit. With irritation in her voice and in front of everyone present, she sniped, “I didn’t touch any patients.” Being brand-new to the field and my role, I hesitated, blushed, and wondered whether there was an exception to the rule of which I was unaware.
Fact: Dr. Drift had not touched any patients. However, she had worked on several computers in the unit, walked in and out of patient rooms, and greeted several people. Soon after this incident, I learned that MRSA bugs are capable of living on computer keyboards for up to six weeks. Of course, the physician needed to wash her hands!
In one fell swoop, Dr. Drift had undermined my authority and confidence as a new safety director. In effect, she sabotaged the hospital’s patient safety program. Like Dr. Drift, hospital leaders unwittingly undermine the culture of safety in hospitals every day. This happens hundreds of times over among direct care providers. Such unsafe “exceptions” become “accepted” patterns, leading to a false sense of security and lack of personal ownership for the problem. Whatever initial safety gains are made after training, they can drift away ever so quickly.
I guarantee you that Dr. Drift thought of herself, and still thinks of herself, as a champion for patient safety in her hospital. Like so many other hospital administrators who set the tone for safety, she was experiencing the very sort of disconnect between an abstract concept and her personal actions. She knew the rule about washing hands before entering and after exiting the ICU, but she didn’t think of herself as someone capable of spreading a lethal infection. Her mind quickly generated an exception to the rule, and she was annoyed for having her seemingly benign behavior challenged.
Interestingly, three years after this incident, my husband and I visited a friend in the intensive care unit at the very same hospital. I was shocked—but clearly shouldn’t have been—that we were able to walk in and out of the hospital unit and in and out of our friend’s room without any staff attending to whether we (or the multitude of my friend’s visitors) washed hands. Signs were posted on the ICU door reminding people entering to wash their hands, but I, who no longer worked there, was the one who had to say something to protect our friend.
Believing that signage alone is sufficient to establish essential safety routines among hospital visitors is unrealistic. And the same can be said about expecting staff to have the ability or time to catch all visitors entering a unit and train them on proper handwashing.
The Good News
In spite of some persistent challenges, significant progress has occurred since Semmelweis’s day and even over the last few years. There is virtual unanimity among tod
ay’s healthcare professionals that proper hand hygiene is essential for preventing the spread of deadly healthcare-associated infections. We now have a set of established hand-hygiene standards for hospitals, and handwashing campaigns have been a focus of patient safety programs in most hospitals.
Yet the rate of healthcare-associated infections is still on the rise. In 2009, leaders of national patient safety organizations met to discuss this escalating problem. Their meeting signaled a new day when these leaders unanimously acknowledged the mounting evidence that virtually every healthcare-associated infection is preventable and that they could no longer be considered the “cost of doing business.”9
Together, this prominent group of patient safety experts established the Chasing Zero Consensus, which refers to the idea that anything other than a goal of zero healthcare-acquired infections is unacceptable for hospitals today. Zero healthcare-associated infections was the agreed-upon goal because the knowledge exists to address this problem and the solutions are often quick, uncomplicated, and essentially cost-free.10
The zero-tolerance goal was not only revolutionary for healthcare; it was also necessary. As legendary football coach Vince Lombardi once said, “Perfection is not attainable. But if we chase perfection, we can catch excellence.”
The Sweet Smell of (a Bit of) Success
Modern healthcare has proven that it has the capacity to radically reduce, if not effectively eliminate, this problem. Consider the case of the subset of healthcare-associated infections that are related to the insertion of central lines, called central line infections.
Central lines refer to long, thin, flexible tubes that are inserted through the skin of the arm or chest to make it easier to deliver medications and fluids over a long period of time or in large quantities. They are often used with patients requiring intensive care, cardiac treatment, dialysis, or chemotherapy. Use of central lines puts patients at increased risk for infections, including dangerous bloodstream infections that can lead to extended hospital stays or death.
These infections account for 15 percent of all healthcare-associated infections and 30 percent of infection-related deaths. They are also financially burdensome, costing up to $40,000 per case.11 Recognizing the importance of eliminating these dangerous infections, Dr. Peter Pronovost from Johns Hopkins University led efforts to develop a straightforward checklist of steps for preventing central line infections. He and his colleagues ended up with a five-part checklist. Verifying that hands have been properly washed is one of the first tasks on the checklist.12
After establishing leadership support, Pronovost and his colleagues were able to establish 95 percent compliance with the checklist and eliminate nearly all central line infections in his hospital.13 Healthcare leaders in Michigan decided to adopt the use of Pronovost’s central line checklist statewide and secured federal funding to support the project. The results were amazing. Including all private and public hospitals in the state, Michigan was able to eliminate 70 percent of central line infections.14 There is hope.
The Bad News
We still have a long way to go. The overall rate of healthcare-associated infections remains high, and the majority of US hospitals are not compliant with recognized industry hand-hygiene standards. Even in the best hospitals, physicians and nurses wash their hands less than half the time required, with compliance rates as low as 30 percent.
Again, why do the best doctors and nurses at some of the country’s leading hospitals still only wash their hands half as often as prescribed? While handwashing sounds like a simple issue, it is actually a complex one. Most of us know when, how, and why we must wash our hands. The issue is not a lack of knowledge. The breakdown occurs in putting this knowledge into action with every patient, every time. There are obstacles in the way of full handwashing compliance at every level. As discussed earlier, too many hospitals still don’t have a hand-hygiene policy in place, and policy represents only the first step in changing employee behavior.
Too Much of a Good Thing?
The importance of handwashing is not at issue. What remains up for debate in the minds of providers is “How much is enough?” It is hard for most of us to believe that the amount of handwashing espoused by patient safety experts is really necessary. It can seem like overkill. To be compliant with policy guidelines, a provider would need to wash his hands many times a day and over a hundred times per week. In a hospital setting, where attention demands are high and the work pace is fast and the hours are long, by-the-book handwashing could come to feel like too much of a good thing. But new research shows that increasing compliance from mediocre to high rates is not enough. Gains are still realized by getting compliance above 95 percent.15
The sheer number of handwashing episodes required in a day represents an obstacle in and of itself. Anything that we need to remember twenty to sixty—or even one hundred—times a day is likely to be missed a time or two. Nobody is perfect. The spell-check factor, as described by Megan McArdle in her book, The Up Side of Down—can spell disaster for patients.
We all go through our lives making a constant string of mistakes, but because nothing bad happens, we’re barely even aware of them. . . . The most dangerous thing about the Spell-Check Factor is that we forget it’s there; we don’t register all the times that we have come close to making fatal mistakes. That one moment when a doctor decides not to wash her hands almost never kills anyone. But millions of such moments kill tens of thousands of people every day.16
In fact, more than one in every twenty-five US hospital patients is dealing with a healthcare-associated infection on any given day, but very few of these are ever traced back to the providers who spread them.17 Intellectually, healthcare workers know hand hygiene prevents infections and saves lives. However, when a worker touches a MRSA-ridden surface and spreads the microscopic bugs around the hospital, he never knows it. “When your mistakes rarely lead to a bad outcome, you lose the necessary feedback that helps you improve.”18 However, as explained by the Swiss Cheese Model and showcased in chapter 7, serious safety events are almost always preceded by a stream of minor errors.
The situation is compounded by the fact that, until recently, healthcare-associated infections were accepted as an unavoidable cost of doing business. Countless providers continue to hold this fatalistic belief. When healthcare-associated infections do befall their patients, many healthcare workers chalk it up to a fate to be expected of people with compromised immune systems. They certainly don’t connect any instance of hand-hygiene noncompliance with their patients’ illnesses.
Without clear feedback connecting actual behaviors with negative consequences, behavior change is not intuitive. Without the ability to connect their handwashing lapses with the lives they affect, providers go on infecting more and more people. The solution requires a shift from the focus on provider behavior and patient outcome to a focus on the process of getting things right. In other words, the process of washing hands must be an outcome in and of itself because providers cannot connect their individual actions with the rate of infection in their hospitals.
Taking It to the Street
When providers and patients finally appreciate the full ramifications that not washing hands has for all of us, we will find a way to make consistent handwashing the norm rather than the exception. Because healthcare-associated infections are now spreading beyond the hospital walls, we must engage our patients. When it comes to hand hygiene in healthcare, we all need frequent reminders to do the right thing. For this to occur, patients en masse must be invited to be part of the solution. A successful public health campaign will not only raise awareness among patients about the importance of proper hand hygiene but will also provide actions that everyone can take to ensure safer care for themselves and their loved ones.
Building Blocks for a Public Health Handwashing Campaign
If the public is going to be inundated with information about proper hand hy
giene in healthcare settings, providers need to be ready for this change. They must be prepared to appreciate reminders from patients to wash hands and to graciously respond to patient requests. To facilitate this process, we need to develop public education that includes tools and language that most any provider, patient, and lay caregiver can and will use. When it comes to behaviors like handwashing—the potentially life-saving behaviors that seem too simple to matter—we need powerful reminder tools that are meaningful to everyone on the team. Effective reminders are what we call sticky messages—brief phrases or jingles that once learned are easily remembered. Sticky messages are short but convey a lot.
The tables below contain information to promote consistent handwashing. Table 3.1 summarizes key points from this chapter; table 3.2 is a checklist patients can use to ensure they are adequately and timely prepared to advocate for their safety; and table 3.3 provides sample language that patients and providers can reference as they think about speaking up for safety and reinforcing others when they do so. Table 3.3 includes a “sticky message” to help people remember when they are supposed to wash their hands. (See Made to Stick by Chip and Dan Heath19 to learn more about crafting messages that people are likely to remember.)
Tables 3.1 and 3.3 are offered merely as examples of the sort of information that can be adapted for use in educational campaigns, public service announcements, hospital and clinic brochures, encounter summaries generated by electronic health records, and other relevant community venues. As described in chapter 6, such material should be tailored to its target audience.
Table 3.1.
What You Need to Know
Healthcare-Associated Infections
Information for Patients
Every year, one hundred thousand hospital patients die as a result of infections that they pick up in US hospitals. Healthcare-associated infections are dangerous, but preventable. Proper handwashing is the single most effective way to stop the spread of these infections.
Your Patient Safety Survival Guide Page 7