Secret monitors find hospital hand washing rate lower than expected

A study using undercover observers to check how often health-care workers wash their hands has offered powerful new evidence that Canadian hospitals’ much-vaunted hygiene rates are more illusion than reality.

Medical students in the study who secretly monitored hand cleaning found that just half of nurses and doctors at a major Toronto hospital soap up as required — far lower than the official rate divulged publicly.

In response to it and other research, a group of hospitals in the area is now planning to electronically measure compliance with hygiene rules, which are considered crucial to preventing the huge and deadly problem of hospital-spread infection.

The facilities hope an automated system will be more accurate than the hand-washing “auditors” used across the country now; staff usually know when they’re being watched and act accordingly.

“We are still under the illusion, based on the hand-hygiene rates that are measured and reported across the province that we are all high performers,” said Dr. Jerome Leis, who led the study at Sunnybrook Health Sciences Centre. “But this is simply not the case.”

And those inflated numbers, he said, provide “little incentive to improve.”

The infections that patients contract after they check into hospital are estimated to cause 8,000 deaths a year in Canada. And health workers’ contaminated hands are considered the primary delivery system for those bugs.

Hospitals, health ministries and others have instituted numerous campaigns in recent years to get doctors and nurses to scrub up more often, while implementing monitoring programs and publicly releasing the results.

Most provinces have reported compliance rates steadily climbing to as high as 91 per cent, a rare tangible success in the drive to improve patient safety.

But experts have long suspected the positive numbers owe at least something to the “Hawthorne effect,” the idea that people perform better when they’re being watched. A study at Toronto’s University Health Network in 2014 used electronic surveillance to try to eliminate the phenomenon and found hand-washing rates were, indeed, much lower without a recognized human auditor hovering nearby.

Such automated systems, though, produce results that can differ depending on how they’re programmed.

At Sunnybrook, Dr. Leis and colleagues instead had two medical students trained as hand-hygiene spies, then simply slotted them into different departments alongside other students, no one being the wiser.

Overall, the “covert” monitors found compliance was 50 per cent, compared to the official rate of 84 per cent.

And while some other research — and Sunnybrook’s own numbers — indicate that doctors are less conscientious about hand washing than nurses, the study found similar performance in the two groups.

Another striking finding was that hand washing by medical residents plummeted from 80 per cent to 19 per cent when the physician supervising them neglected to clean. The authors urge those doctor-teachers to set a better example to their trainees.

The research has provided a more accurate picture of the situation, acknowledged Dr. Mary Vearncombe, Sunnybrook’s infection-control director and one of the study authors. But she stressed that even using non-covert auditors, the hospital’s performance has improved over the last decade, and internal data suggests that at least one key infection — the super-bug MRSA — has declined in tandem.

But why is it such a challenge to get health-care professionals to wash their hands when required?

Part of it is the effort required; following the rules can mean cleaning up hundreds of times a day, said Leis.

Vearncombe said she has also heard colleagues say they simply forgot, not surprising given many are “very, very busy” and performing more complex tasks than ever.

The Toronto hospitals are putting together a study of electronic monitoring, which would probably be used in addition to the human auditors, she said.

It may be something that others should consider, as well, despite push-back from staff when it’s been tried outside Canada, said Chris Power, CEO of the Canadian Patient Safety Institute.

“Many of the care providers feel it’s very intrusive,” she said. “But I think as a health-care provider you have a responsibility (to ensure) your hands are clean and you’re not transmitting disease.”

Meanwhile, tests of an experimental electronic system developed at the Toronto Rehabilitation Institute — which sounds a buzzer to remind staff to use soap dispensers – have produced “exciting” results, says Geoff Fernie, the hospital’s research director.