There is growing evidence that hospital managers are hiding poor hand hygiene practices in order to meet infection control targets.
This claim was made by Annette Jeanes, director of infection prevention and control at University College London NHS Foundation Trust (UCLH), to delegates at the Infection Prevention 2013 conference in London this week.
An infection control consultant nurse, she claimed current hand hygiene audit procedures were fundamentally flawed, with some hospitals reporting 100% compliance when the reality was probably much lower.
Her comments come after she carried out an investigation into existing hand hygiene reporting and monitoring systems.
She said: “When I started to look at the data, relatively early on it became clear that performance monitoring tables had not included low risk hand hygiene opportunities, so straight away the data was looking fairly flaky.
“Around 25% of those carrying out the audits did not report low scores and instead redid the audit. Any reports of 85% compliance or less were routinely disregarded and in some cases staff were told that they were being observed and were asked to change their behaviour in order to get a higher score.
Any reports of 85% compliance or less were routinely disregarded and in some cases staff were told that they were being observed and were asked to change their behaviour in order to get a higher score
“When we quizzed infection control nurses we were told that in some cases managers would not let them submit low data and some were only allowed to collect the data and were not allowed to input it.”
Jeanes began to monitor hand hygiene compliance on the wards at UCLH in 2005 when hand hygiene compliance was around 20%.
She revealed: “I would stand on the wards and I would see some nurses and doctors failing to wash their hands, so I started a programme of monitoring compliance. In 2008 we trained staff to carry out audits and sent them out to collect data, with the trust setting a target of 85% compliance. Currently we are achieving 97% compliance and the trust is extremely happy with that.”
But, she claimed, these impressive figures were not backed up by her own experience of observing the wards.
She said: “These figures do not collate with what I am seeing on the wards, which is more like 24% compliance. I am speaking to patients who say their doctor did not wash their hands and their nurse did not wash their hands when changing their dressing.
“This made me start looking closely at the methodologies used when collecting data and there seemed to be a lot of variation. As wards expand and services change and buildings go up and come down it becomes increasingly difficult to make sense of the information we are collecting.
“If you are only monitoring for 20 minutes a few times a month then what does 100% compliance actually tell us? If one person in five doesn’t wash their hands then you are recording 80% compliance, but this is a very small part of the picture.”
And when quizzing staff about the impact of hand hygiene audits, many described it merely as a ‘tick box exercise’ and criticised infection control leads for ‘having nothing better to do than nitpick and tell tales’.
In addition, only 42% of those in charge of auditing had been given formal training and just 6% had that training updated regularly. And these members of staff were rarely given enough time to carry out the audits.
These findings led Jeanes to change the auditing procedures at UCLH.
She said: “Traditionally hospitals have focused on collecting data and not on hand hygiene and the data they collect is not particularly reliable or useful. We need some sort of reliable data focused on improvement and risk, not just hand hygiene opportunities. We need to provide training and support and we need to give staff time to monitor the situation properly. In future we have got to do much more than just observe.
“When we are collecting data it seems we are missing the point and that is that we should be focusing on infection prevention and control and preventing the transmission of micro-organisms. Currently the emphasis is too much on collecting data and too little on what we are actually trying to achieve.”
We need some sort of reliable data focused on improvement and risk, not just hand hygiene opportunities. We need to provide training and support and we need to give staff time to monitor the situation properly. In future we have got to do much more than just observe
As a result she has drawn up a new auditing tool that provides assurance and identifies areas for improvement.
“It is about putting hand hygiene into context and integrating it into all elements of hospital care,” she said.
“The system looks at key areas such as skin problems, glove usage, the environment, information, education etc and gives a weighted score. You can then see exactly where the problems and opportunities for improvement are and, once you get 100% in one area, you can review the process and include other areas that you may need to work on.
“We have got to demonstrate to patients and to our organisations that hand hygiene audits demonstrate value and to do that we need to focus on reducing risk and increasing opportunities for improvement. It has got to be less about achieving targets.”
Her comments were welcomed by infection prevention nurses in the audience. One claimed: “At the moment we use hand hygiene monitoring as a tool for punishing rather than for reducing the transmission of infection.”
Another added: “I do not see it as a failure if we get 75% compliance. It is about looking for ways you can improve. We spend so much time trying to get that extra few per cent on our score, but that does not necessarily make any difference to outcomes. We need to have realistic expectations rather than just fighting to get our rates up because the hospital up the road is reporting 85% compliance and ours is lower.”