Cross-Sectional Study of Impairment of Mental Status and Attitudes of Disinclination as Barriers to the Participation of Adult Medical-Surgical Inpatients and their Families in a Hand Hygiene (HH) Reminder Program Directed at Health-Care Workers (HCWs)

Background: The CDC’s 2002 guideline for HH suggests that health-care settings implement programs to “encourage patients and their families to remind HCWs to decontaminate their hands.” However, reported participation in reminder programs varies from 57% to only 3%. Hospital stays have shortened, with a tendency to reserve hospitalization for particularly sick patients. If hospitalized patients are too sick to participate in a program of HH reminders or disinclined to do so, barriers to participation in a HH reminder program may exist. Objective: To assess the prevalence of impaired mental status among adult medical-surgical inpatients and also to assess, among patients and family members visiting them, attitudes toward giving HCWs HH reminders. Methods: 143 inpatients at the VA Medical Center in Omaha were randomly selected in July-August 2009. A single interviewer saw patients in the morning (8 to 10 a.m.) in weeks 1 and 3 and in the afternoon (2 to 4 p.m.) in weeks 2 and 4. Assessment included responsiveness and visible risk factors for infection (e.g., catheters). If a patient was responsive and cooperative, the St. Louis University Mental Status examination (SLUMS) was administered. Additional questions, posed to patients and visiting family, included willingness to remind HCWs to decontaminate their hands, whether they felt comfortable doing so, and whether they felt it was their responsibility to remind HCWs. Results: Of 143 patients, 94 completed SLUMS, with 20 scored as normal, 33 scored as mild neurocognitive disorder, and 41 scored as dementia. 93 of the 143 patients answered questions about attitudes toward giving HH reminders, with 63 willing, 52 feeling comfortable, and 40 feeling responsible. 26 displayed a combination of willingness, comfort, and responsibility (WCR) to give reminders. 9 (6%) patients were well-suited for a HH reminder program (normal mental status and WCR). Family was present and WCR in 8 of 143 encounters, including 7 visiting patients who were not well-suited. Overall, 16 (11%) encounters involved patients or family who were well-suited. None of the well-suited encounters included any of the 10 patients with endotracheal tubes or chest tubes. Of 46 patients with urinary devices, only 18 could complete SLUMS while 76 of 97 patients without them could complete SLUMS. Conclusions: Our finding that only 6% of patients had normal mental status and were WCR corroborates the report of 3% participation in a HH reminder program. In few encounters were family members present who might provide reminders that an ill patient could not. Patients at greater risk for infection were less likely to be capable of providing reminders. The CDC guideline suggesting encouragement of reminders may be inappropriate in some acute care settings.