Many health-care workers don't wash their hands as often as they should

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Most people don't wash their hands properly. (KEN GIGLIOTTI / WINNIPEG FREE PRESS) Photo Store

Germ factories

STARTING last summer, the Winnipeg Regional Health Authority began auditing each ward in each hospital to find out how often staff members washed or sanitized their hands. Armed with clipboards, auditors have spent days watching to see whether staff washed hands before and after touching patients, before handling dressings or open wounds and after contact with body fluids such as blood, or contaminated instruments. Auditors even looked to see if staff had fake nails and jewelry, which are germ magnets. The first round of audits is almost complete.

Here are some results:

 

Health Sciences Centre

58 per cent compliance rate

• 13 wards with superbug outbreaks were audited late last summer.
• Among the worst handwashers are doctors, patient transporters and radiology staff.
• Another round of audits on other wards during the winter didn't produce better results. Staff in the surgical intensive-care unit only had a 57 per cent compliance rate, for example. Staff members in the newborn intensive-care unit fared much better. They washed their hands 98 per cent of the time.

 

St. Boniface

57 per cent compliance rate

• Two wards, 5E and 6E where a superbug outbreak was the worst, were audited.
• Among the culprits were health-care aides, nurses and patient transporters. Nurses washed their hands only 54 per cent of the time.
• Followup audits earlier this year in other wards didn't produce much better results. In one ward, the compliance rate was only 42 per cent.

 

Grace

74 per cent compliance rate

• Eight wards were audited early on because they were epicentres of the superbug problem.
• The compliance rate was pretty high, but training was going on during the audit, so handwashing was top-of-mind among staff.
• Nurses had a 77 per cent compliance rate while staff who put in IVs and lab staff fared poorly with only a 36 per cent compliance rate.

 

Concordia

58 per cent and 48 per cent compliance rates

• Reports dated Feb. 2012 looked at two wards -- N2W and N2E -- and found very low compliance rates.

 

Seven Oaks

24 per cent compliance rate

• One report found nearly every class of health-care worker had extremely low compliance rates. Patient transporters, who washed their hands barely 10 per cent of the time, were flagged as a big trouble spot, since they travel and carry germs throughout the hospital.

 

Misericordia

61.5 per cent compliance rate

• That covers the acute-care wards only, in an audit completed in July 2011.

 

Victoria

46 per cent compliance rate

• Covers seven wards, including the ER and the ICU in a report generated March 6, 2012.
• In a later report, dated April 4, 2012, handwashing on the SC ward was abysmal at 37 per cent. Doctors there had a three per cent compliance rate.

 

Personal-care homes

The handwashing practices at the WRHA's nursing homes were also audited and generally did fairly well, with an 82 per cent compliance rate over a period of nine months. That could be because staff has more of a routine and fewer intense emergencies than in a hospital, making it easier to make handwashing a habit. Winnipeg's care homes come off well when compared with one 2005 study in two Ontario long-term-care homes where staff members washed their hands only 15 per cent of the time, and rarely for a long enough period of time.

There were some nursing homes where staff members washed their hands only a third or a quarter of the time. To see how the facility that cares for your loved one fared, see below for an interactive feature.

 

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   • How often do you wash your hands?

The WRHA has a dirty little secret.

Frontline staff at the Winnipeg Regional Health Authority -- everyone from doctors to dieticians -- don't wash their hands nearly as much as they should.

Those are the findings of a series of handwashing audits started last summer and still underway in hospitals and personal-care homes across Winnipeg.

The hand-hygiene audits, obtained by the Free Press following an access-to-information request, were prompted in part by a growing plague of superbugs -- antibiotic-resistant infections such as MRSA and C. difficile that can be fatal.

In general, most hospitals had roughly 50 per cent or 60 per cent compliance rates. That means health-care workers washed their hands roughly half the time they should have -- before and after patient contact, before and after eating or touching wounds, dressings or contaminated instruments, for example.

Many wards fared far worse, though.

For example, one audit completed in February found staff on seven wards at the Victoria General Hospital washed their hands only 46 per cent of the time. Meanwhile, a ward at Concordia Hospital had a 41 per cent compliance rate in one audit.

Health Sciences Centre, the province's largest hospital, did a little better. Data compiled last September found staff in 13 wards washed their hands 58 per cent of the time.

The goal is at least 70 per cent compliance.

Winnipeg's hospitals are far from the only ones failing at hand hygiene.

Handwashing is the single most effective way to combat the spread of infections and superbugs, but getting staff to comply has become one of the most intractable problems in hospitals all over the world.

Research shows even at the best of times, compliance rates hover only in the 50 to 60 per cent range -- roughly where Winnipeg's hospitals fall.

"We know that hand hygiene is dreadful across the board," said Dr. John Embil, director of the WRHA's infection-control program. "We're as good, if not better, than the others."

Doctors have among the dirtiest hands, even though they should be models of clean behaviour. On seven wards studied at the Vic, doctors washed their hands only one-third of the time. On another ward at the Vic, doctors had 30 chances to wash their hands before and after touching patients, instruments and wounds and washed only once.

Physicians did a little better in two audits done last year at St. Boniface General Hospital. There, they washed their hands 63 per cent of the time.

In general, though, doctors are failing at hand hygiene, Embil said.

What might really get under patients' skin is the fact staff was often much better at washing hands after having touched a patient than before -- what the reports called "self-protective behaviour."

Why health-care workers are failing at basic handwashing is still a mystery. Research has shown staff understands the benefits of clean hands and tends to be much better at it when something nasty, such as the H1N1 flu, is circulating. But in the unpredictable rush of hospitals, handwashing sometimes falls by the wayside. It's even lower on the weekend, for some reason.

The deadly SARS virus that almost crippled Ontario's health-care system in 2003 made infection control top-of-mind for hospitals across Canada. After that, infection-control standards became part of how hospitals are accredited.

Two years ago, the WRHA flunked an accreditation review, which found Winnipeg hospitals failed to meet 13 of 17 national standards for containing and reducing infections.

The audits began in earnest last summer as a response to the accreditation review and as a way to get to the bottom of a recent spike in VRE infections.

Vancomycin-resistant enterococci, one of the new superbugs, has infected more than 1,100 Winnipeggers since January of last year. It's not as debilitating as other superbugs, but it is seen as a harbinger of bigger problems in infection control.

"VRE was the flame under everyone's backside to get moving," said Embil, who preaches the benefits of hand hygiene, using blunt language combined with humour.

He once dressed up as Soapy the superhero for a Dr. Seuss-inspired storybook about the benefits of proper handwashing. And, he hosts a very popular one-day conference every year called Bug Day.

Before even stepping onto a ward, first-year medical students get a crash course in handwashing, repeated again in their third year. New residents get the same kind of course. One is happening Monday, in fact.

And the hospital has frequent "safe huddles" on wards, where staff is reminded again and again about the importance of handwashing. Eventually, Embil hopes it becomes as habitual as putting on a seatbelt when getting into a car.

Embil said draconian measures, such as suspending chronically poor handwashers, won't work. In order to get compliance rates closer to 70 per cent, it's better to have voluntary buy-in from all staff, he said.

But if cajoling staff with gentle reminders and polite nagging doesn't work, public shaming might. Early next year, the WRHA will begin posting the results of its hand-hygiene audits online, as Ontario does.

"There's no more messing around. There are no more excuses," said Embil. "We all need to get on the same page."

maryagnes.welch@freepress.mb.ca

Bugged by superbugs

LIKE all health authorities, the WRHA is coping with a rise in superbugs -- nasty infections that can't be killed by regular antibiotics. Here's the rundown:

MRSA

Methicillin-resistant staphylococcus aureus is a staph infection that's particularly tough to treat with antibiotics. Infections can be life-threatening, invading the bloodstream, bones and lungs. It's generally seen as the worst of the superbugs.

The numbers: MRSA is the most prevalent superbug in Winnipeg hospitals, but cases have been relatively stable in the last year, between 75 and 140 new cases a month. Rates are well below the national average. In March, the last data available, there were 97 cases.

C. difficile

Clostridium difficile causes mild to severe diarrhea, nausea and abdominal pain. In some cases, it can be fatal. It's the most common superbug in hospitals, and it's spread via feces.

The numbers: Cases in Winnipeg hospitals have also been fairly stable in the last year, between 35 to 50 new cases a month. In March, there were 37 cases.

VRE

Short for vancomycin-resistant enterococci, VRE is found in feces and can spread through inadequate handwashing. It's a bad one, but not as virulent as C. difficile or MRSA. Instead. VRE is seen as the canary in the coal mine, evidence of less-than-perfect infection-control measures.

Those stricken with the bug can develop infections in the urinary tract, the bloodstream or in organs. Most people don't get sick, though.

The numbers: VRE's been on the rise in the last couple of years, starting at HSC and moving to other hospitals. So far, there have been upwards of 700 cases, but fewer than five people have become ill. In January of last year, there were just 27 new cases. In January of this year, that number quadrupled.

Interactive map: Handwashing compliance in Winnipeg personal care homes

Green markers indicate care homes that scored more than 70% during the April to December 2011 reporting period.  Red markers show care homes that scored below 70%.

Click on any marker to open a box with details on the home and its score in August 2011 and April through December 2011.

You're washing incorrectly

MOST people don't wash their hands properly. It's more than a quick rinse. Here are some tips:

• Take off your rings and other jewelry. They are germ repositories.
• Use a good squirt of soap. Hot water alone doesn't kill the germs.
• Lather under your nails by hooking your fingers together and rubbing, or lightly scraping your nails on your palms. Get between your fingers by interlacing your fingers. Don't forget the tops of your hands.
• Take your time. You should keep lathering for as long as it takes you to sing Happy Birthday twice. The whole process should take at least 30 seconds.
• Try to use a paper towel to turn off the taps so you don't get old germs on clean hands. You should even try to use the hand towel to open the bathroom door when you leave.
• Alcohol-based hand-sanitizer gels work in a pinch, but soap and water are better.

Watch the kids wash correctly

Kids at the Red River Ex got a crash course in handwashing last week at a health exhibit. See the video below to watch and learn.

Republished from the Winnipeg Free Press print edition June 23, 2012 A6