Healthcare hand washing: Solutions or Scapegoats?

Healthcare providers have known for at least 165 years that hand washing is a critical component in disease prevention. So why have generations of healthcare providers failed to follow the rule?
We agree that hand washing is one of the fundamental practices to prevent infection in any healthcare setting. But there is no doubt, that it is only one of a panoply of interventions required for infection control, says Darrell Horn. (CBC)

On May 6, 2013, the WRHA announced their new hand hygiene campaign, acknowledging Hospital Acquired Infections (HAI’s) as the fourth leading cause of death for Canadians.

Experts believe now that HAI is responsible for the deaths of up to 18,000 Canadians a year. Math on the back of a napkin would suggest one or two Manitobans dying daily.

WRHA CEO Arlene Wilgosh has stated, “this is a serious ongoing issue that poses a real and very significant risk to those we care for. Something new has to be done to address it." With that diagnosis complete, the prescription was handed down: hand washing, lots more of it and punishment for those who fail to comply.

Well the initial results of the experiment are in and the numbers, in terms of compliance, aren’t that encouraging. But what do the numbers really represent and does pursuit of an 80 per cent goal really address the problem?

Name, blame and shame, a paradigm for individual accountability often applied in business, has been iterated now as the solution that will finally compel compliance with hand washing protocols by all those dirty doctors, nurses and other professionally regulated care providers.

Those at the sharp end of care, the last contaminated provider to touch the patient, will be held responsible for spreading germs and will be punished. There will be no more hiding behind the skirts of systems thinking, within some vague rubric of systemic responsibility.

If this scourge of rampant infection is indeed the result of laziness, indifference and simple bad habits, then the sooner healthcare providers learn a lesson the better, correct? Let’s fix this problem, and fix it now by holding the guilty feet to the regulatory fire.

We hear it over and over again these days; we have to identify the root cause and fix it. According to the WRHA, strict enforcement of rules is necessary to keep us safe.  

Healthcare providers have known for at least 165 years that hand washing is a critical component in disease prevention.  So why have generations of healthcare providers failed to follow the rule?

Tradeoff between thoroughness and efficiency

The answer is in the necessary tradeoff between thoroughness and efficiency that has to be made each and every day, in the course of the hundreds of human transactions made by care providers on every shift, in a complex system where resources are limited and often the demand exceeds them.

Too many patients to care for, and not enough time to follow rigorous hand hygiene protocols.

We agree that hand washing is one of the fundamental practices to prevent infection in any healthcare setting. But there is no doubt, that it is only one of a panoply of interventions required for infection control.

Dr. Michael Gardham, in charge of infection prevention and control within the University Health Network in Toronto, recently stated that while Ontario hospitals’ compliance with hand washing protocols has risen dramatically in recent years it has not brought about a commensurate decrease in infections.

The World Health Organization (WHO) identified hand decontamination as only one of the critical elements of personal hygiene that will reduce disease transmission.

Dirty hospitals

According to the WHO, an equally crucial concern is prevention of disease transmission from the environment. This relates to the fundamental level of cleaning of the hospital environment.

The public has been alerted to this in recent media reports, including the CBC’s Marketplace (episode: Dirty Hospitals) for example.

Ninety per cent of microorganisms are present within visible dirt. Routine cleaning is necessary to ensure a hospital environment which is visibly clean and free from dust and soil.

There are policies and procedures specifying the frequency of cleaning and cleaning agents for walls, floors, windows, beds, curtains, screens, fixtures, furniture, baths and toilets, and all reused medical devices. Medical devices and surgical equipment must be disinfected or sterilized according to rigorous standards.

Cleaning, disinfection and sterilization are among the most complex processes in healthcare. Is the WRHA confident that the necessary resources are in place and the relevant rules obeyed in these processes?

Which of all of these is the critical element in reducing and eventually eliminating HAI’s, the root cause, if you will?

The answer: none of them and all of them.

Dragon to slay?

There is no root cause to the problem. When you think you’ve found the root, you will invariably find a collection of other contributory causes.

And if there is no dragon to slay, then who will we blame? Who will we punish?

Our need for retributive justice is not so easily satisfied. And such rough justice most certainly won’t make us safe. The notion of a dirty doctor or nurse as the sole or even major cause of HAI’s is a canard.

Such a simplistic notion of cause and effect in the complex healthcare environment is a dangerous one, and naive in the face of established understanding within the fields of epidemiology as well as complexity and safety science.

Everyone in the healthcare system is at the front line of this fight, including patients. The diligent hands of cleaning staff may be equal to the skillful hands of the surgeon in determining our fate during the course of a hospital stay.

A visitor is just a likely to spread the bug that gets you. Sharing a room with another patient substantially increases your risk of acquiring infection, and the most rigorous hand washing by providers will only nominally mitigate it.

Solutions, not scapegoats

Our concern about the WRHA announcement is the lack of acknowledgement of the systemic nature of the true solutions, apparently devoid of a plan to marshal the required resources.

Under the Manitoba Workplace Safety & Health Act, Sec. 43(1): “A worker may refuse to work or do particular work at a workplace if he or she believes on reasonable grounds that the work constitutes a danger to his or her safety or health or to the safety or health of another worker or another person.”

Who, under the lens of ”name, blame and shame” will be the first health care provider to draw the line and say, “I have too many patients, and not enough time to follow proper hand hygiene protocols. I am refusing this work on the grounds that it constitutes a danger to the health of another person."

Will it then be labour legislation that ultimately compels the minister of health and the WRHA to properly resource a systemic solution that will keep patients safe?

It’s time for solutions, not scapegoats. 

Darrell Horn is a patient safety advisor on behalf of Healthcare System Safety & Accountability Inc.


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