Most hospitals in Ontario reported having formal hand hygiene policies, but about two-thirds lacked a monitoring process to ensure the procedures are followed, according to a study released Thursday.

The Ontario Hospital Association and provincial government commissioned the report by the Canadian Institute of Health Information.

The report follows outbreaks of C. difficile at some Ontario hospitals and last month's report by Ontario's auditor general that also concluded hospitals need to do more to prevent and control infections.

Researchers at CIHI analyzed survey results from 103 of Ontario's 123 acute care hospitals. Of the hospitals that responded in January and February 2008, 99 per cent said they had a formal hand hygiene policy in 2008.

Just over one-third of hospitals responding, 38 per cent, said they had a monitoring process, the report said. In early 2007, 23 per cent of the 97 hospitals that responded to CIHI's survey said they had monitoring in place.

CIHI's report measuring hand hygiene and other infection controls is an important first step, but it will take a shift in culture — similar to the decades it's taken to increase use of seat belts or change attitudes toward smoking — to make hand hygiene a habit among health-care workers, said Dr. Michael Gardam, medical director at the University Health Network in Toronto.

"In order for that hand washing to change, we have to get inside health-care workers' heads," said Gardam, who is also the director of infectious disease prevention and control at the Ontario Agency for Health Protection and Promotion that was created in response to SARS.

Taking hygiene down to the personal level — for example, by asking if a health care worker's family member has caught an infection in hospital — and turning to these diligent hand washers to get the word out works much better than relying on top-down orders from managers, said Gardam, citing research at six major hospitals in the U.S. by the New Jersey-based Plexus Institute.

Infection control goes viral

Just as marketers targeting a personal music player for teens won't use adults in a focus group, it's better to start with nurses and doctors at the grass roots level who care about hygiene rather than assuming senior staff will set an example that trickles down, he said.

Making hygiene fun also helps. For example, when dedicated hand washers attend an improv exercise where the spread of MRSA to patients and loved ones is illustrated by shaking hands smeared with chocolate pudding that represents germs, it leads to changes in thinking that lectures won't achieve.

"In medicine, we think about randomized clinical trials, not about doing improv," Gardam said.

Taking this behavioural approach, rather than an epidemiological one, may seem obvious but it's "so touchy-feely, it's foreign" to health-care workers, he added.

The standard approach is to use certified infection control practitioners to educate hospital staff and document hygiene measures, such as counting how often the alcohol gel dispensers need to be refilled.

In 2008, 42 per cent of participating hospitals had both a certified infection control and a physician or doctoral professional trained in infection control, and 80 per cent of hospitals said they had one of these professionals, the report said.

To be certified, infection control practitioners need two years of experience, and many of these positions are new, Gardam noted. As in other fields of health care, many of the experienced professionals will be retiring in the next 10 years.

Other steps, such as putting alcohol gel dispensers where health-care workers need them, still need to be improved at hospitals, Gardam said.

In June 2007, Ontario launched a $1-million pilot program called to improve hand hygiene among the province's health workers and reduce hospital-acquired infections such as C. difficile and methicillin-resistant Staphylococcus aureus or MRSA.