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Handwashing: The Next Regulatory Crackdown

Cleanliness is next to Godliness, it’s been said. And Godliness, like a Visa card, is arguably priceless. But that doesn’t mean you can’t put a price on cleanliness. And now someone has: $1.98.

That’s how much it costs a hospital every time a health care professional fails to wash his or her hands, according to a study released last week.

A doctor fails to wash her hands after examining a patient, spreading a few germs that could seed a new infection and perhaps necessitate a round of tests and antibiotics. Kaching! Ring up, on average, $1.98.

A nurse forgets to wash up after taking a patient’s blood pressure, then moves on to the next room. Kaching! Another $1.98.

An aide removes Patient A’s food tray and delivers a fresh one to Patient B without the benefit of a handwashing intermezzo. Kaching!

Two bucks may not seem like a lot of money, but it adds up fast when you consider the thousands of interactions that can occur in a hospital every day. To be precise, it adds up to a whopping $1.77 million a year at a typical 200-bed hospital, Duke University Medical School researchers reported at the Interscience Conference on Antimicrobial Agents and Chemotherapy, held in Washington.

Indeed, as we prepare to welcome a new administration, handwashing, I would argue, is the metaphor of the day.

The key to stemming this health care expense is simple and uncontroversial. Handwashing is highly effective. It takes less than half a minute. And one can hardly turn around in a hospital without bumping into a sink or a hand sanitizer dispenser. Yet even highly trained professionals either forget or semiconsciously cut corners with some regularity. And so do we non-medical personnel as we go about our days holding handrails and subway straps in this season of sniffles.

All of which raises the question: Why aren’t all of us—doctors and nurses especially, but all of us really—more diligent about washing our hands? Or more to the point: What would it take to make handwashing a higher priority?

As it turns out, a large number of studies have addressed that simple question, and the answers have relevance far beyond the sink. Indeed, without a stretch, they get to the very heart of human nature and, in doing so, they say something important about smart governance and policymaking on a larger scale—something worth considering as the country closes the door on an era of regulatory slumber and unencumbered greed and considers anew how to get people and institutions to behave in more socially responsible ways.

Indeed, as we prepare to welcome a new administration, handwashing, I would argue, is the metaphor of the day.

To start, let’s consider last year’s survey sponsored by the American Society for Microbiology and the Soap and Detergent Association—one in which the famed polling company Harris Interactive won the questionably attractive contract to go undercover in restrooms and observe, firsthand, what 6,076 adults actually did. It found that while 92 percent of adults claim they always wash their hands after using a public restroom, only three-quarters truly do. Other studies have found considerably lower rates, in the 40 to 50 percent range.

So the first challenge is getting people to face the problem squarely.

Here’s one way: In a 2002 study, researchers clandestinely observed whether doctors washed their hands after having direct contact with patients and confronted those who didn’t. Each offending doctor was then enrolled in an “importance-of-handwashing” educational program. When asked in followup interviews which part of the educational program was, in the doctor’s opinion, most effective in getting him or her to recommit to regular handwashing, it turned out that no part of the program had made as big an impression as the mere act of getting busted in the first place.

In short, every doctor already knew that handwashing is important. But, well, laxness happens (or “hand washing apathy,” as a 2002 research report called it). And there is nothing like enforcement—and the shame that comes with being made an enforcee— to revitalize one’s commitment to doing the right thing.

Fortunately, there are similarly effective ways of getting people to change their handwashing habits that do not involve being pulled over, cited and sentenced to a remedial hygiene class. All of us, it turns out, have the power to bring handwash scofflaws to the sink. In one study of women using a public restroom, only 11 of 28 washed their hands when they thought no one was there to see them, but 24 of 31 did so when a another woman was plainly in the room. In other words, the simple knowledge that one is perhaps being watched can cause significant changes in behavior—a truth familiar to anyone who has considered quietly reaching for the cookie jar, whether in the kitchen or on Wall Street.

A second study compared handwashing rates among women using the restroom in a bar, under two kinds of situations: when another woman was present and made eye contact and initiated a conversation, and when another woman was present but talked on a cell phone the whole time and did not make eye contact. The results were robust: Women in the first situation were twice as likely to wash their hands compared to their counterparts who thought they were being ignored, 56 percent to 27 percent.

This is not to say that handwashing or any other single behavior can singlehandedly (as it were) eliminate hospital-acquired infections, which affect up to 2 million Americans each year and kill an estimated 100,000. And some parts of the solution may come from other, unexpected places.

A 2004 study at a teaching hospital in New York, for example, found that about half of all neckties worn by doctors harbored disease-causing bacteria—a prevalence five times greater than for ties worn by other hospital staffers who had no contact with patients. No one knows if neckties really contribute to the spread of disease inside hospitals, but statistics like those led the British Medical Association in 2006 to recommend that doctors “refrain from wearing functionless pieces of clothing, such as ties” (and has helped launch renewed interest in bowties, which give doctors the professional look they want without flopping from one germy patient to the next).

Financial incentives can obviously help, too. In October, the federal Medicaid and Medicare programs announced they would no longer reimburse hospitals for the treatment of infections caused by those hospitals. No more sugar daddy picking up that $1.77 million tab.

All told, however, the lesson for anyone trying to encourage best practices, whether they are hospital administrators or government regulators, is that at least as important as making smart policy changes—fixing the “neckties” in the system—is creating a system that is truly transparent and that includes a real threat of enforcement, something there has been precious little of during the Bush administration.

A few plain-clothed observers could go a long way toward cleaning up the worlds of government and finance. No doctor, no mortgage derivatives trader, no recipient of a big defense department contract wants to be seen doing the perp walk to handwashing class.

Rick Weiss is a Senior Fellow at the Center for American Progress and Science Progress.

Tags: public health, regulation

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