Even Covid-19 May Not Be Causing Your Doctor To Wash His Hands
by Michael MillensonIf you think the grim coronavirus death toll is causing health care workers everywhere to always wash their hands, think again.
A recent research letter published in The Journal of Hospital Infection examined whether it’s “possible to achieve 100 percent hand hygiene compliance during the Covid-19 pandemic.” The medical center involved in the research, Queen Mary Hospital in Hong Kong, had reached a pre-Covid-19 hand hygiene rate of over 75 percent.
Yet the hospital’s goal of complete compliance proved surprisingly elusive. In one pediatric ward devoted to suspected or confirmed Covid-19 patients, doctors and nurses followed hand hygiene rules 100 percent of the time, but in another ward with similar patients and staff, compliance was 83 percent, or about one-fifth less.
Given Covid-19’s risk to providers as well as patients, this was “unexpected,” the researchers admitted.
The Queen Mary study supports what infection control experts have long maintained: awareness isn’t enough. Doctors and nurses, particularly during a pandemic, understand that hand hygiene is “the most important intervention” to reduce the staggering death toll from infections, as the American Journal of Infection Control put it.
Still, cautions Chris Hermann, a physician and founder of the company Clean Hands-Safe Hands, “Hand hygiene is a simple concept, but to change it is more complex.”
There have been literally hundreds of studies on how to get health care workers to consistently wash their hands, with interventions running the gamut from reminder signs to electronic monitoring. Yet clinicians at U.S. hospitals pre-Covid properly cleaned their hands “less than half the times they should,” according to the Centers for Disease Control and Prevention (CDC).
Even with Covid concerns at the top of mind, doctors and nurses may not perceive when they forget to wash or fail to properly follow the guidelines properly. This misplaced certainty is known as the “overconfidence effect.” It was memorably lampooned by humorist Garrison Keillor in stories about the fictional town of Lake Woebegon, where “all the women are strong, all the men are good-looking, and all the children are above average.”
Unfortunately, our national effort to dispel the illusion of hand hygiene competence is truly woebegone. The CDC doesn’t track hospitals’ hand hygiene rates, and neither the government nor private accrediting groups requires hospitals to even reach a certain compliance level. It’s enough to show that you have an improvement program.
Whenever individual hospitals’ hand hygiene rates do become public, it’s clear that prestige doesn’t presage protection. As the journalism group ProPublica reported in early March, just before the number of Covid deaths began to soar, “Infection control has been a recurring problem…at the first tier of treatment centers” designated by the CDC to handle an infectious disease outbreak.
In March, the Leapfrog Group’s Leah Binder and I wrote an opinion article calling for an end to the government’s hands-off approach to improving hand hygiene. For now, though, government action seems unlikely.
In just a few months, Covid-19 has brought sickness and death to untold numbers of doctors, nurses and others on the front lines of care, as well as to tens of thousands of other Americans they were valiantly trying to help. A crisis, however, cannot by itself instantly cause improvement.
“Covid, frankly, is not enough,” says Hermann.
Hermann adds that he’s skeptical that Queen Mary attained the 100 percent hand hygiene compliance it claims, noting that the use of infection control nurses and the small number of patient interactions reported suggests the rate might be much lower when there’s no one around to watch.
Nonetheless, Hermann agrees with the conclusion that the commitment “to build up a good hand hygiene culture” by the leadership of the high-performing ward was central to its success.
While it can be difficult to believe that hospital hand hygiene is still a concern post-Covid-19, what’s needed now is changing processes, not blaming people. For the sake of patients and providers alike, the effective tactics and technology that too many hospitals have eschewed, such as better training and electronic monitoring, must be urgently embraced as a matter of life-and-death.