Healthcare News & Insights

Surprising truth about hand hygiene during COVID-19

Proper hand hygiene has never been discussed more than it is today. Hospitals are working harder than ever to keep patients safe, even while their providers jeopardize their own health. One might expect that raised awareness due to the pandemic would lead to improvements in hand hygiene, but a recent study reveals without intervention, hand hygiene rates in hospitals have largely decreased since the pandemic began.

Recently, an Internet of Things (IoT) hand hygiene system provider collected and analyzed data across 40 hospitals using its system to determine if hand hygiene had improved with the heightened awareness of COVID-19. The facilities included community and academic hospitals of all sizes, from small critical access hospitals to large 1,000+ bed facilities. Over a 12-week period that spanned six weeks before and after hospital operations were impacted by COVID-19 patients, over 8.45 million hand hygiene opportunities were recorded. To provide the best possible comparison of COVID-19’s impact on hand hygiene, data were compared six weeks before and after each hospital experienced a significant influx of COVID-19 patients.

The results were surprising. The hospitals without real-time interventions experienced a 40% relative decrease in hand hygiene. The graph below represents aggregate hand hygiene performance data collected for hospitals without real-time reminders. The trend of stagnant or reduced hand hygiene performance was consistent across the board, no matter the size or geography of the hospital.

When the data were presented to hospital leadership teams, they were shocked. It was largely expected that hand hygiene would rise during COVID-19, not fall. It became clear that there was a problem to be solved. At a time when healthcare workers are equally concerned about their well-being and that of their patients, why aren’t hand hygiene rates higher?

There are many reasons for this decline in hand hygiene rates, some of which are specific to COVID-19 and others are common challenges healthcare organizations face when operating under normal circumstances.

“If a pandemic did not change hand hygiene, no amount of vigilance ever will. Awareness of hand hygiene was at an all-time high as providers were literally afraid for their lives, but hand hygiene still decreased. We have to look at it not as a people problem, but as a system and human factors issue,” said Adam Webb, MD, Chief Quality Officer, Emory University Hospital.

Perception vs. reality

It’s been widely reported that clinical providers clean their hands less than half the time they are supposed to. Yet, when surveyed, most clinicians believe they have excellent hand hygiene performance rates. This is because there’s a gap between provider perception and reality.

The graph below illustrates the perception (blue) of hand hygiene versus reality at the same time (gray). The horizontal axis represents hand hygiene performance – farther right is better. The height of the bars represents the number of clinicians in each performance range.

The vast majority of providers, 80%, estimate their hand hygiene performance is between 80% and 100%. However, the reality is vastly different. Over 70% have a hand hygiene rate below 50%. Remarkably, fewer than 1% of the providers have hand hygiene rates that are within the ranges that they believe to be true.

Healthcare workers genuinely believe they’re cleaning their hands every time they’re supposed to. This is because every time they think about performing hand hygiene, they do it. But when they don’t think about performing hand hygiene, they don’t notice they’ve forgotten to clean their hands. Without reminders, providers often forget to clean their hands.

Misconceptions about PPE

Another reason that providers often fail to sanitize is a misconception around PPE, specifically gloves. There have been anecdotal but consistent observations that front line staff are wearing gloves more frequently, and many times inappropriately, in an effort to protect themselves. Despite what hand hygiene policies indicate, front line clinicians often incorrectly assume that gloves are a replacement for hand hygiene.

If patient care requires the use of gloves, the CDC recommends sanitizing before putting on gloves, before touching the patient and after the removal of gloves.

Disruptions to usual workflow

One of the biggest reasons clinicians sanitize less frequently than they should is they’re busy. It may seem obvious, but the busier a clinician gets, the harder it is to perform routine practices, like hand hygiene.

Providers are facing all kinds of new challenges related to COVID-19. They’re busier, they have to use PPE more and they have to deal with the craziness of the unit. It’s no wonder providers are often forgetting to sanitize. Still, hospital leadership needs a solution that will ensure hand hygiene rates don’t drop.

Solution to improving hand hygiene during COVID-19

The IoT hand hygiene system also collected data from its customers that had implemented real-time hand hygiene reminders. In these hospitals, if a provider forgets to sanitize when they’re supposed to, they hear a natural language voice reminder. Despite the stress and chaos of COVID-19, all of those hospitals experienced an increase in hand hygiene. During the COVID-19 outbreak, there was 38% relative improvement in hand hygiene for the hospitals with real-time voice intervention.

This proves that despite having the best intentions, clinicians can only be re-educated so many times with the same results. For effective change, providers must be made aware when they’re expected to perform hand hygiene, in the moment. The graph below demonstrates that during COVID-19, there was a 38% relative improvement in hand hygiene in health systems with the voice reminder turned on, in contrast to a 40% relative decrease with no reminder.

It’s clear that without interventions, the stress of COVID-19 surprisingly yields poor hand hygiene. The gap in provider perceptions versus reality, the increased use (and misuse) of PPE and the disruption to usual workflow cause providers to clean their hands less, despite an increased awareness of hand hygiene. The solution to improving hand hygiene is obvious: real-time interventions when providers forget to clean their hands.

Author: Chris Hermann MD, PhD, is the founder and CEO of Clean Hands-Safe Hands.


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  1. Rocco Perrinetti says:

    When you have to go to the article to help you understand the graphs something is missing. Really bad.