QUESTION: I recently had an appointment with a medical specialist. I got called into the clinic room where I waited for the doctor; and I noticed a few "wash your hands" posters. When he came in, I swear he didn't use the hand sanitizer. I couldn't be sure. And I didn't want to ask -- but I was kind of grossed out. What should I have done? Is it ok to question the doctor about hand washing?
ANSWER: Your concerns about hand washing are certainly justified. Poor hand-hygiene practices are largely to blame for the spread of germs within health-care settings.
"These things don't fly through the air -- with very, very few exceptions," says Dr. Mary Vearncombe, who is the Medical Director of Infection Prevention and Control at Sunnybrook Health Sciences Centre.
"They get around on a vehicle, and that vehicle most often is our hands."
If you ever suspect that your doctor, nurse or other health-care provider forgot to use the hand sanitizer, by all means raise the question. But, in reality, most patients in your situation are reluctant to do so.
"Very few people would ever be comfortable asking their health-care providers if they've cleaned their hands," acknowledges Dr. Vearncombe. "Our patients feel very vulnerable," she explains. "They are in an imbalanced power relationship with us, so it is really hard for them to ask."
Indeed, some patients fear that their treatment could be jeopardized if they challenge the doctors and nurses on even routine matters such as hand hygiene. Their care will certainly not be affected, but it's a worry for them nonetheless.
Surveys going back almost a decade found that Ontario patients didn't want to be placed in the role of a police officer to ensure that doctors and nurses wash their hands.
As a result of these surveys, most of the hand-hygiene education in Ontario has focused on the health-care providers themselves.
Since 2007-2008, Ontario hospitals have been required by provincial law to report their hand-hygiene rates. In some hospitals, such as Sunnybrook, designated staff members routinely observe interactions of health care providers with patients to track if they are actually washing their hands at the appropriate times.
Before mandatory reporting took effect, a study carried out at a few hospitals had revealed that hand-hygiene compliance rates were "abysmally low," notes Dr. Vearncombe.
The rate at Sunnybrook, for instance, was originally less than 40 per cent -- similar to many other hospitals. "We have made great increases in our hand-hygiene compliance, and the most recent results show our overall rate is now 87 per cent."
Even so, it could be better. For that reason, some infection-control experts -- including Dr. Vearncombe -- believe it might be time to finally recruit patients into the process."We know from recent surveys of our patients that they know health care providers should clean their hands and they expect it of us, even though they are reluctant to ask," says Dr. Vearncombe.
"In the past decade, a lot has evolved and focusing on patient engagement has begun to dramatically change the health-care landscape," says Sudha Kutty, director of Quality Improvement Strategies and Adoption at Health Quality Ontario, a provincial-government agency.
"Patients are a huge additional resource to help with this issue. We just have to find the best way to engage with them," adds Ms. Kutty.
A pilot study at Sunnybrook has been exploring what role patients could play.
Three of the hospital's inpatient wards were selected for the pilot. As part of the study, an information card was placed on the bedside table whenever a room was cleaned and prepared for a new patient.
"This little card explained in lay language what to expect" when a health-care provider entered the patient's room, says Dr. Vearncombe.
The cards stated that "Your care provider should clean their hands: 1) Before contact with you; 2) Before a procedure; 3) After a procedure; and 4) After contact with you."
The cards also included the catchphrases: It's okay to ask staff, "Did You Clean Your Hands?" and "Reminders help everyone!"
Posters carrying similar messages were hung on the walls of the patients' rooms and in the hallways. Some staff also wore buttons that read: "Ask me if I cleaned my hands."
Dr. Vearncombe said the goal was to make patients aware of what healthcare providers are supposed to do to prevent the spread of infectious organisms. As well, the initiative was meant to empower patients, essentially giving them permission to ask the question.
Ms. Kutty notes that "Ask Me" buttons can be effective tools in breaking down barriers between patients and their care providers.
"Anecdotally, I have heard about other hospitals that have tried this way of empowering patients and found that the buttons served as a launching pad for a discussion," says Ms. Kutty. "Patients felt that the buttons gave them a segue into a conversation" that they might have otherwise avoided.
Overall, the number of patients who actually quizzed staff about hand washing wasn't exceptionally large in the Sunnybrook pilot study. But, more telling figures can be found in the hand-hygiene compliance rates on the three pilot units -- they went from 81, 85 and 89 per cent to 92, 88 and 95 per cent, respectively. Dr. Vearncombe calls that trend "promising."
Sunnybrook now plans to roll out the program throughout the rest of the hospital's inpatient wards.
In the long run, Dr. Vearncombe isn't expecting a huge surge in patients asking this difficult question. However, even a small increase could be enough to prompt health-care providers to remember to wash their hands when they are in contact with patients. "Knowing that a patient might ask will probably motivate you to improve your behavior," she says. "That's the crux of it."
So, the next time you suspect a health-care worker may have skipped the hand sanitizer, don't hold back. Everyone benefits when fewer germs are spread around.
Co-authored by Paul Taylor, Personal Health Navigator at Sunnybrook.
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