A few times a week, Michael Gardam
rounds up his posse and sets off to patrol the hallways
of Toronto's University Health Network (UHN) hospitals.
Weapons at the ready, the tough-talking, no-nonsense
gang is hunting rare game: the handwashing-compliant
physician.
"We just walk around and wait for
people to wash their hands," says Dr Gardam, the director
of infection prevention and control at the UHN. "Then
we jump on them."
Any squeaky-clean MDs the posse
apprehends are rewarded with a two-dollar gift certificate
for Tim Hortons.
COFFEE
CONTROVERSY
The coupons are just a small part of a new hand hygiene
program launched last month at the UHN's Princess Margaret,
Toronto West and Toronto General hospitals. The strategy,
designed by Dr Gardam, includes a renewed effort to
remind physicians and other hospital staff to wash their
hands by email and with posters, an increased number
of alcohol gel hand sanitizer dispensers and a change
to a new brand of gel, Purell.
After the news of the strategy
broke in the Globe and Mail in mid-November,
Dr Gardam started to hear feedback. "Either people thought
it was great or the worst idea ever," he says.
Complaints can be grouped into
two distinct categories: the health food argument and
the moral outrage argument.
Dr Gardam is dismissive of the
former. "Two dollars at Tim Hortons is not going to
create a mass obesity problem — and they don't
have to buy donuts."
What about the people who allege
it's outrageous to reward doctors for doing something
they should be doing anyway for safety reasons? "People
who say that haven't thought it through," he says. "I
agree it is morally very upsetting that people don't
wash their hands, but I wouldn't get upset at strategies
to fix it. For example, our staff has relatively high
rates of flu vaccination because we give them chocolate
bars. People on staff have complained that healthcare
workers should be doing this for the good of their patients,
that they don't need rewards. But those arguments don't
work well for healthcare workers — it sounds preachy."
THE
GEL SOLUTION
Changing the brand of alcohol gel — though not
as exciting as the promise of free snacks — may
in fact turn out to be the most important aspect of
the new hand hygiene policy.
The last kind of hand sanitizer
the UHN used had some pretty major problems. Doctors
complained it felt weird on their hands. The bottles
were too small and didn't have a way to display how
full they were. The brackets that were supposed to keep
the dispenser on the walls would detach unexpectedly.
"If they weren't falling off the walls, they were empty,"
complains Dr Gardam. The one before that was even worse.
Used at the UHN until just before SARS hit, it dripped
and damaged the floors. "There was a real move afoot
to limit the amount we used so as not to damage the
floors," he recalls. (He's quick to deny the gel problems
contributed to any SARS transmission.) Now, after bringing
in a handful of hand sanitizing gel vendors and letting
staff vote, Purell is in and thousands of new dispensers
are being installed.
STARBUCKS
EFFECT
A similar project at the Cedars-Sinai Medical Center
in Los Angeles was the inspiration for Dr Gardam's Tim
Hortons idea. Cedars-Sinai experimented with offering
coffee-shop incentives by offering doctors a 10-dollar
Starbucks card for washing up — very generous,
compared to the UHN's two-buck reward. "Ten dollars
at Starbucks and two at Tim Hortons buy you basically
the same amount of coffee," quips Dr Gardam.
The Cedars-Sinai results, reported
at the Infectious Diseases Society of America annual
meeting in October of this year, showed that over two
years physician handwashing compliance rose from a very
typical rate of under 50% to nearly 90%, and the MRSA
rate in the hospital was cut in half. "Given the amount
of coffee they drink in the area, I'd think they'd have
been very successful," says former Cedars-Sinai physician
Dr Warren Foster, now a professor of obstetrics and
gynecology at McMaster.
However, the biggest jump in compliance
at Cedars-Sinai occurred after the administrators followed
through on a threat and suspended one noncompliant physician's
hospital privileges. The UHN hasn't discussed that idea
yet, but Dr Gardam says it's the "logical conclusion"
and "part of the overall strategy." "It comes down to,
are we serious about this? Do we have serious compliance
issues from staff?" he says. "Then you move into the
realm of discipline."
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