Florence, and the machines

The core of infection control is rather simple.  You don’t need a lot of fancy education, you just need a few ounces of common sense.  You can learn fancier stuff later.  When I teach infection control, either at new employee orientation, or to nursing or other departments (staff meetings, inservices, etc.), I talk about "Florence Nightingale nursing."   What I mean is a back-to-basics approach to preventing the spread of infection.  Most of what we do is dictated by what we’ve known for more than a hundred years.  These are the 3 tenets I always come back to, for new employees and in my own work:

1. Wash your hands
2. Keep the environment clean
3. Keep the sick away from the well

Now, not all of those ideas belong to the Lady with the Lamp.  But they are basic science that has been known for a very long time.  If you know nothing else, you can answer the grand majority of infection control issues with one of these 3 things. Let’s start with the first one.

Hand Hygiene

If we did more of this, we’d have to worry less about #2.  We, the supposed bringers of health, spread infection all over the place.  We touch the patient, the IV pump, the meal tray, the patient’s toothbrush, the patient, the bedsheets, the IV site.  And our hand washing is dreadful.  We do it wrong, we don’t do it enough, and we don’t do it at the right time.  A common measurement for hand hygiene compliance is to watch a worker entering and leaving the patient room.  Did that nurse clean her hands on the way and on the way out?  Yes?  Put a check (tick) in the box.

That’s nice.  But if she washed on the way in to the room, then emptied the bedpan, and flushed the toilet, then gathered the patient’s supplies for hygiene, then helped the patient brush his teeth with the same hands that just emptied the bedpan…?!  Then the hand washing on the way in the door isn’t worth much, is it?  Now the patient has a mouth full of his own bedpan germs on his toothbrush.   The World Health Organization promotes “5 Moments for Hand Hygiene”.  This is great.  This is what staff SHOULD be doing.  What happens in the room is key; not just on the way in or out. But it’s a lot harder to monitor while you are making rounds on the unit. 

I think sometimes, the staff think that’s all I do.  “Are you watching us wash our hands?” someone will always ask when I’m out on the floors making rounds.  They ask with that half-kidding/half-not-kidding smile/sneer.   No, I think: I’m reviewing charts, looking at the damaged ceiling tiles the contractor left, seeing if our new disinfectant smells too strong, checking the levels on the sharps boxes to see if our waste contractor is coming often enough,  and checking high dust in the waiting rooms.   No, I’m not washing you wash your hands.  I did that yesterday.  “Not today,” I smile.

So, they think that’s all I do.  Then why don’t they think, “We’ve hired someone whose sole job is to watch hand washing.  It must be that important.  I should do more of it.”

Hand Hygiene is also the answer to most of the employee health questions I get.  'I took care of Mr. B before we knew he had MRSA.  What do I do now?'  Well, did you wash your hands? There is no shortage of hand hygiene products, formulations, and dispensers available on the market and in facilities.  Why don’t staff perceive risk, and wash more often?  Once, an employee called out sick with a new diagnosis of C.difficile.  She called the Employee Health office to find out if her sick time would be paid under workers’ compensation.  No, it isn’t.  If you got it here, it’s because you ate it.  I told you to wash your hands. 

Patients need hand hygiene, too.  This is such an overlooked area, I think.  It was nice to see some presentations and posters at the SHEA conference last month focused on patient hand hygiene.  In the acute care setting, maybe we don’t think about it is as much because the patients are in their beds most of the time.  But I’ve worked in acute rehab and in behavioral care, where the patients are out of their rooms as much as in.  They share meal times, exercise equipment, activities and supplies.  They are in contact with many more people, many more environments, and all the germs that come with increased mobility. A hand hygiene program should include the patients.   Sanitizer dispensers can be out of reach.  Little packets of wipes on the meal try have been shown to be literally impossible to open for some patients.  Patient hand hygiene needs to be actively promoted and implemented by their caretakers, helping them when they can’t help themselves.  Like hand hygiene rounds.  Sort of like when we have toileting schedules.  Practical?  I don't know.  Valuable? Absolutely.

 What’s your practical patient hand hygiene solution?