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Why Hospital Infection Rates Continue to Climb Despite Improved Hand Hygiene?
  At a table of Infection Prevention Control Experts, presenting opinions of why present hand hygiene rates are reportedly as high as 90% yet infection rates continue to climb, led to the following conclusions:
1 Hawthorne Effect: Most audits are conspicuous; no longer secret, or spontaneous. Hand Hygiene (HH)
  auditors are often noticeable; thereby raising awareness that an audit is taking place. Some programs actually announce their intent to audit. This lack of discretion has potential to inflate the numbers.
2 No accountability/ Performance Management: There is the troubling concern of what to do with individuals found to have poor hand hygiene. Repeat offenders with poor Hand Hygiene (Physicians often cited amongst the poor performers) pose a major challenge. Current bodies of knowledge have not given guidance on what IPs should do in cases involving poor performers. This results in lack of consistent practices on how to manage poor performers.
3 Inter auditor variability: If two auditors audit an area at the same time, there is a chance for inconsistent readings due to: level of experience, situational understanding, or my favorite, Hawthorne effect (known auditor versus unknown auditors).
4 Audits concentrated on weekdays: One of the IPs joked that, since the bulk of hand hygiene audits are done on weekdays, it implies infection has banking hours. Since most audits are done during weekdays, it does not allow for data collection or knowledge of how night, evening, and weekend staff perform.
5 Lack of focus on the quality of hand hygiene: Hand Sanitizer companies have recommendations of wetting hands with sanitizer for at least 15 seconds. This practice is essential in ensuring that the ABHR will work to kill the pathogens. However it seems that a compromise has been struck and that any attempt at HH even if less than the minimum time seems to be acceptable.
These are suggested solutions to the problems that were raised: A result of asking, “Why?”
1 External Inspectors should validate Hand hygiene programs as prerequisite to mandatory reporting.
2 Establish a criterion to ensure audits are a good sampling of all hours of the week.
3 Research into how to correct for Hawthorne effect.
4 Renewed focus on quality of hand washing to promote washing technique.
5 In a world of abundant technology more emphasis is needed on ways to avail this technology to hand hygiene auditing.
In conclusion, as players in infection prevention, we are armed with more technology, human resources, and intellect to allow us to do better. To make changes and improvements, we should continue to ask, “Why despite improved had washing rates do we continue to see hikes in infection rates”. Asking why is a good start to closing this growing gap between high rates of Hand hygiene despite even higher infection rates. We cannot afford to be complacent and continue to do things the way they have always been done.  
Article Source: http://info.debgroup.com/blog/bid/256480/Why-Hospital-Infection-Rates-Continue-to-Climb-Despite-Improved-Hand-Hygiene
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