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Why Hospital Infection Rates Continue to Climb Despite Improved Hand Hygiene?

March 26, 2013
Hospital Infection Rates

I am a huge fan of ‘The Easter Ham Story’.  In the story, a little girl watches her mother prepare the Easter ham and decides to ask her mother why she cuts off both ends before putting it in the pot. The mother of the little girl responds with only, “That’s how its always been done.”  


What makes this story a favorite of mine is because I always find myself compelled to learn why we do things the way we do them?  It’s also a great story to share with others around the anxiety of asking the question “Why?” A lot of the time, I hear people say,” ….that’s how it’s always been done”.  Sharing ‘The Easter Ham Story’ with people gets them to think and participate in looking for improvements and solutions.


Recently,  I had an opportunity to engage a table of Infection Prevention Control Experts on their opinions of why present hand hygiene rates are reportedly as high as 90% yet infection rates continue to climb.  The enlightening discussion that arose, lead to these 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.

Just in case you were wondering how ‘The Easter Ham Story’ ends, the mother of the little girl goes on to ask her own mother why they cut off the ends of the ham. It turns out that the tradition of cutting off the ends of the ham had no major significance other than the simple explanation of not being able to fit the whole ham in the small pots they had back in the day. In other words, Grandma did not have the means to make it work back in the day.  


These are suggested solutions to the problems we 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.  


About Barley Chironda


Barley Chironda Barley Chironda is a Infection Preventionist at a large community hospital in Ontario, Canada. He enjoys process improvement and implementing change aimed at lowering Health-care acquired infections.  Follow @barleychironda on twitter or LinkedIN for an opportunity to stay in the know of current developments in Infection Prevention and control. 






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