Published: February 21, 2019
Ms. Maureen Banks, RN, DNP, MBA, NEA-BC, FACHE, is the Chief Operating Officer and Chief Nursing Executive of the Spaulding Rehab Network. She shared her experience leading Spaulding Hospital Cambridge to dramatically reducing infection rates through improvements in hand hygiene.
Working to prevent infection
Spaulding Hospital Cambridge is a long-term acute care hospital in greater Boston. They care for patients who are chronically critically ill, which make them particularly susceptible to healthcare-associated infections. It’s not surprising that Spaulding places a high priority on infection prevention and control. Like nearly all hospitals, one of the infections Spaulding works to prevent is Clostridioides difficile, or C. diff. C. diff is a common side effect of antibiotic utilization, and the CDC estimates that it caused nearly half a million infections in the United States in 2015.
Before this hand hygiene improvement project began, the facility already had intensive cleaning practices. This included using an ultraviolet robot to sanitize the gym where patients do rehab exercises, and disinfecting patient and public bathrooms with a disinfectant spray on objects that people commonly touch, such as patient wheelchairs and the curtains around a bed. The hospital also uses two ‘bundles’, a term used to refer to sets of evidence-based practices that prevent infection. Hand hygiene compliance is also included in hospital policies, training, and protocols.
These practices were showing a decline in infection rates, but Maureen identified a missing piece. “When we put in the hand hygiene [project], it was like a stone dropped” she says, describing the rapid decline in C.diff rates once improved hand hygiene was added to the approach.
Can technology help us do more?
Even with the existing efforts to prevent and control infections, Maureen continued to look for ways to reduce patients’ risks of infection. As part of her doctoral program, she decided to pursue a solution to improve hand hygiene, using a sensing technology called BioVigil. Maureen chose this technology because it records hand hygiene opportunities at critical moments as well as the performance of hand hygiene. It also gives feedback to patients and provides staff with immediate reminders. Maureen sought to answer three questions:
Maureen’s literature review showed that while this technology had shown success in acute care hospitals, it had not been implemented in hospitals like Spaulding Cambridge, which focuses on post-acute care. Post-acute care hospitals have a longer average length of stay and a greater opportunity to have an impact on healthcare acquired infections.
Tracking hand hygiene through sensing technology
Spaulding Cambridge worked with BioVigil to use their technology at the hospital. Spaulding staff wear badges with a colored light to indicate hand hygiene status. Green means hand hygiene has been performed; yellow is a reminder to clean hands; and red means hand hygiene should occur immediately. When staff clean their hands with handrub, they cup their hand over the badge. If there is enough alcohol on their hands to indicate good hand hygiene, their badge turns (or stays) green.
The technology also uses beacons at the entryway to patient care areas. When staff reach one of the key moments for hand hygiene (for example, entering or exiting a patient’s room), the beacon detects that there is a hand hygiene opportunity and communicates to the staff member’s badge. If the staff does not clean their hands, the badge will remind the staff by making a sound and vibrating. It will turn yellow to let patients and co-workers know hand hygiene should be performed. If hand hygiene is not performed by the end of the reminder, the badge will turn red. The badge can be used to record hand hygiene for any of the key moments.
Depending on requirements set according to their role, staff have up to 60 seconds to confirm that their hands are clean. For example, staff who need to put on personal protective gear when they enter a room get a bit of extra time. When washing at a sink, the badge confirms the required time for a complete cleansing with soap and water at the sink has occurred. Importantly, this applies to all staff who have regular patient contact or regularly enter patient rooms, including nurses, physicians, therapists, food service staff, and others.
Each week, BioVigil provides reports on each person’s compliance. This includes the total number of hand hygiene opportunities, the number of opportunities taken, the number where the health worker needed a reminder, and the ones that were completely missed. These reports are sent to each health worker, their supervisor, and the quality department. Patients also receive a card explaining what the system does, why the staff are wearing the badges, and what the red, yellow, and green lights mean.
Immediate feedback leads to rapid results
This BioVigil technology was introduced in July 2018. Maureen was prepared to advocate to staff to participate, but she reports there was surprisingly little resistance. Part of this, she admits, “is because it was very supported by clinical leaders,” but she credits the staff with a strong desire to keep patients safe in their care.
Staff and supervisors quickly saw the power of data to improve hand hygiene. The personal reports each person receives allowed supervisors to use gaps in hand hygiene as a coaching moment. As Maureen says, “no one wants to be the one who caused an infection,” and the immediate reminders from their badges helped people connect their own behavior to the risk of infection. This helped people see how their own hand hygiene, rather than the larger concept of hand hygiene, was a vital part of their work. The color coding also developed a system of peer pressure. Maureen described her excitement hearing staff in the hallways saying, “Hey, your badge is red! Go do hand hygiene.”
As staff were successful, they began to see the system as a way to validate their strong performance. Over time, Maureen says, “You knew that you were successful, and that motivated you to be able to be proud of your own success.” In addition to a source of pride, it also gave staff another way for their supervisors to provide positive feedback on their work.
On a management level, hospital leadership can look at the data in different ways. For example, they noticed lower compliance on weekends, and used that to target more training for staff who work on weekends. They noticed that staff who had English as a second language had lower rates of early participation in the program, prompting them to adapt their methods for explaining what the project was and how it connected to patient safety. They also noticed higher compliance when staff were exiting a room; this is also supported by literature in other settings, showing that health workers perceive their hands as dirtier after being in a patient’s room.
The benefits of better hand hygiene
The adoption of the technology and the response from team members were both positive results in the beginning. But what was the impact? There is a publication pending with the full data, but we are able to share some of the results.
Within six months of installing the BioVigil system, Spaulding Hospital Cambridge saw a statistically significant increase in hand hygiene at key moments compared to previous rates, which were based on direct observation. They also saw a large increase in the consumption of Purell, the alcohol sanitizing handrub they use. Based on the use of handrub, they quickly understood that the previously reported rates of handwashing, which were measured by direct observation, had significant limitations – limited number of observations, staff being aware of the observer, and the fact that most of the data focused on the day shift, resulting in over-reporting of compliance rates. The team now feels that they have an accurate understanding of the level of compliance.
Spaulding Cambridge also saw a rapid drop in C.diff cases. Early in the study, when there was one case of transmission, they were able to use data to see exactly how the infection was spread from one room to another, and to use that information to prevent future spread. While the importance of hand hygiene for preventing infection is well known, it’s rare to be able to show how a specific gap in hand hygiene led to an infection at the health worker level. In the 12 months before the hand hygiene project, the incidence of GDH+/toxin+ C. diff infections was 9.59 per 10,000 patient days. There have been no GH+/toxin+ C. difficile infections in 4 of the 7 months since, decreasing the incidence by 75% to 2.44 per 10,000 patient days.
As they sustain much lower rates of infection, they are now able to look into the possibility of removing some precautions (such as the use of certain protective garments). This may have benefits in costs saved and improve quality of care by saving staff time by making it easier for them to enter patient rooms. Maureen noted that in hospitals where patients share rooms, this could also mean that fewer beds are unavailable when an infection is present in that room.
Based on the success of the project at Spaulding Cambridge, Maureen is planning how to scale the project up to other hospitals within the Spaulding network.
Why did it work?
Reflecting on the initial success of this project, Maureen credits a few key factors.
Thorough measurement: BioVigil makes it possible to measure 100% of hand hygiene opportunities when health workers enter or exit a room. An estimate from BioVigil’s web site says that a hospital the size of Spaulding Cambridge has about 18,000 opportunities each day. It also measures adequacy while most existing measures only register whether a person washed their hands. This shows whether their hands are truly clean.
Accountability and feedback: This system has prompted staff and supervisors to share feedback about each person’s compliance. Compared to data at a facility level, this can motivate staff to take ownership of their role in preventing infection. It also drives home the urgency, and the specific link to keep patients safe. Feedback on the overall success of the project has also helped to build even more support and better compliance. As Maureen said, “The need to do coaching has dwindled as people have seen the results.”
Leadership: The technology was only a part of this project’s success. Spaulding Cambridge’s leadership, starting with the President, showed a strong commitment to improving hand hygiene. They were consistent in praising staff who had high levels of participation and responded quickly when there were gaps. This helped all staff understand the importance of the program.
Finally, it is important to note that these hand hygiene improvements were carried out in the context of a larger focus on infection prevention and control. Improved hand hygiene is an effective and actionable way to reduce infection rates. Even perfect compliance isn’t sufficient to prevent infections on its own, but it’s a vital part of any efforts to prevent healthcare-associated infections.
Editor’s note: This profile is the second in our series of leadership profiles on hand hygiene. We will continue to feature success stories on hand hygiene throughout 2019. To nominate a hand hygiene leader, please contact us at firstname.lastname@example.org.
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