Hand washing, a key anti-flu strategy, often neglected by health care workers.

AS THE 2009 INFLUENZA A(H1N1) virus expands its reach, health officials continue to stress the importance of hand washing as the first line of defense in prevention. Particularly in health care settings, hand antisepsis has long been recognized as a key factor in minimizing the spread of pathogenic microorganisms and limiting health care–associated infections. Yet getting health care workers, including physicians and nurses, to wash their hands remains a problem. In response, new patient safety programs from the Joint Commission and the World Health Organization (WHO) are placing their initial focus on improving compliance with hand hygiene standards. On September 10, the Joint Commission launched its Center for Transforming Healthcare, which seeks to identify effective quality and safety practices that can be implemented at a broad range of institutions, said Mark R. Chassin, MD, MPH, Joint Commission president. Its first target: hand cleanliness. “We conducted a little poll giving institutions about 35 of the nastiest quality problems they now face and asked them to identify for themselves what their top problems were,” Chassin said. “The problem receiving the most votes was hand hygiene.” The Joint Commission’s program comes a few months after the May 5 launch by the WHO of the First Global Patient Safety Challenge, which is intended to spur worldwide commitment by policy makers, health care workers, and patients to make cleanliness in the health care setting a top priority. Its first charge is to achieve consensus on the most effective strategies for improving hand hygiene in health care. The WHO has also published a guide to implementing its health hygiene strategies (http: //whqlibdoc.who.int/publications/2009 /9789241597906_eng.pdf). To date, 5752 hospitals in 122 counties have signed on to the challenge. The evidence for hand hygiene is compelling. According to the Joint Commission, an estimated 1 in 136 patients in the United States (2 million cases annually) become seriously ill from hospital-acquired infections, resulting in annual direct medical costs of up to $45 billion; prevention programs could cut those costs by up to $31.5 billion. And while the evidence is limited, studies suggest a higher burden of health care–associated infections in developing countries, with the WHO citing 1-day prevalence surveys of single hospitals in Albania, Morocco, and Tunisia that found such infections in almost 1 in 5 patients. While it seems obvious that health care workers should be practicing optimal hand hygiene, a variety of factors work against this, said Kathy B. Kirkland, MD, an associate professor of medicine, infectious disease, and international health at Dartmouth Medical School in Lebanon, NH. “One problem is that failure to clean hands is not proximally related enough to the infection acquired by a patient to create its own feedback loop—so there is a disconnect,” Kirkland said. “No one knows whose hand hygiene event failure is associated with a specific patient infection, so it is difficult to make that accountability link as easily as if you touched patients and they broke out with boils.” Beyond the disconnect, there are other obstacles faced by health care workers in their efforts to achieve optimal hand hygiene. The Joint Commission listed such barriers as ineffective placement of dispensers or sinks, insufficient or nonexistent education and just-in-time coaching, a safety culture that fails to stress hand hygiene at all levels, the awkwardness of cleaning hands when carrying items, the interference of gloves with the process of cleaning, a misperception that wearing gloves eliminates the need for hand hygiene, forgetfulness, and distractions. Further, compliance data are often not collected or reported accurately or frequently. But health care workers should know they are susceptible to carrying around infectious organisms, and that cleaning hands is effective in minimizing the risk of infecting others. Studies have shown that 80% of hospital staff who dressed wounds infected with methicillin-resistant Staphylococcus aureus (MRSA) carried the organism on their