Dr. Hugo Sax (front, right) is the Head of Infection Control, Hospital Epidemiology and a Consultant in Infectious Diseases at the University Hospital of Zurich in Switzerland. A human-factors engineering and implementation scientist, Dr. Sax is perhaps most well known for creating the "Five Moments of Hand Hygiene" which has been adopted by the World Health Organization as the prototypical way of improving hand hygiene.
Dr. Sax recently visited Ann Arbor and our research team (picture). He was kind enough to sit down with me and share his wisdom regarding hand hygiene for the vascular access community. Of note, Dr. Sax completed the ICJME form and disclosed research support from Ecolab for the evaluation of an alcohol-based hand sanitizer product in a previously published study.
VC: Why did you choose hand hygiene as your area of research?
HS: I really didn’t' choose it: rather, it chose me. I had the opportunity to organize a nationwide hand hygiene promotion campaign in Switzerland in 2005 and after this I was hooked. Plus, it exemplifies THE challenge in infection prevention, no? Germs are invisible and infection always happen later. This makes hand hygiene operate in a system that basically never gives feedback to your behavior. Such systems are bad teachers: how do we keep doing hand hygiene when nothing perceivable happens when we don’t? So we need to better rely on mental models, as we discuss in this paper.
VC: Why is hand hygiene so important? What data suggests that it helps prevent infection?
HS: This is indeed a crucial question! Rather than go into all the data, I wonder if we could do a little survey here? Here is my email: firstname.lastname@example.org. If you don’t mind, please send me a few words on the exact mechanism by which you think hand hygiene prevents a patient from getting any of the big 4 healthcare-associated infections (primary bloodstream infection, urinary tract infection, pneumonia, or surgical site infection). For example, you may think about how central line infections are thought to come about and in what step exactly hand hygiene would intervene to prevent them. Plus, if you feel comfortable, tell me what went on in your head while you were thinking about this. In return for participating, not only will I answer each email personally, I will also send you the overall result of the survey and a signed reprint of our ‘Five Moments’ paper. We know very little about vascular access providers and hand hygiene so this will be a new and important project I think. Please note: I will treat your answers as absolutely confidential.
VC: Can you tell us a bit about the WHO "My 5 moments of hand hygiene" campaign?
HS: When organizing the Swiss Hand Hygiene campaign in 2005, we decided to measure hand hygiene performance before and after the campaign in over 100 hospitals at the same time. That needed a robust concept, one easy to understand, train, and monitor hand hygiene in a broad range of healthcare settings. So we tried a lot of different approaches, did a lot of videotaping and drawing, showed it to various people to tap into what I call their mental models -- that is, how they picture the world around them. Finally, we came up with the idea of five fingers, five moments: thus, making it ‘sticky’ with respect to memory and translation of the concept. But actually, the central piece of the concept is the patient zone, comprising the patient skin and immediate environment, which is colonized with the patient’s microbiome. The goal of this step is simple: no germs in, no germs out.
VC: When inserting vascular catheters, variation in how we perform hand hygiene exists. Some use alcohol-based rubs, other chlorhexidine scrubs or antimicrobial soap with water, etc. Which is best?
HS: Alcohol-based handrub is certainly the quickest and most effective way to get rid of the transient hand flora, if the hands are visibly clean. If the hands are soiled, then best to use soap and water.
VC: In your opinion, what are the greatest problems or barriers in performing hand hygiene?
HS: I think the biggest problem is cognitive overload - that is, clinicians are often busy doing all sorts of things in the day from thinking about patients to delivering treatments and interventions. Given all of this, its not hard to see how hand hygiene can "slip" out of focus - especially when approaching a patient. The other problem is lack of feedback that occurs if/when you skip hand hygiene. If you don't know you made a mistake, how can you fix it?
One way of solving this problem is to develop what I call "muscle memory" and "cues to action." For example, in Europe, we drive mostly stick shift cars and when we pull up to a red traffic light our hand automatically grabs the stick and shifts it into 1st gear, otherwise we feel uneasy. This happens unconsciously while watching people cross the street or listening to a radio program. Hand hygiene should be the same - an unconscious act that actually puts us at ease.
VC: How has human factors research influenced your approach to studying hand hygiene?
HS: I believe that everyone takes genuine pleasure in organized, streamlined work flow. This translates well into my studies of hand hygiene. For instance, it is always a good idea to place dispensers conveniently where they are visible, accessible and can be used. It also makes sense to make sure that people fall in love with the experience of using them – a bit like car makers purposefully design the sound and feel of a shutting door of an expansive sports vehicle to be an addictive experience. I view hand hygiene much the same way - a safety component that can be designed such that it is easy, accessible and enjoyable for all those that useit.
VC: If there was one thing you hoped people would know about hand hygiene, what would that be?
HS: That our hands are meant to heal!
Please do take the time to email Dr. Sax regarding his hand hygiene survey by emailing him here. Dr. Sax will keep all replies confidential and will reply to your emails individually.