“President Garfield didn’t die from an assassin’s bullet, but rather from a doctor’s dirty hands.”

Recently after a doctor’s appointment I went to a nearby lab to have blood drawn for routine tests. I asked the phlebotomist to wash her hands to which she replied she already had. She had washed her hands in another room after the last patient, done some other work, come into the room, put gloves on, then went and used a shared computer, before finally drawing blood. When I asked, she refused to wash her hands in front of me. So I refused to let her proceed. The same with the second tech. Finally the third washed her hands correctly in front of me. But not again before she left the room!
I reported this to the absentee owner!

Do you ask “Doctor, Did You Wash your Hands?” If not, why not?
Everyone knows, including our physicians, that proper hand washing is the most effective patient safety measure right?
Your physician and other clinicians (e.g. nurses, PTs, lab techs drawing blood) should wash their hands before and after each patient, both times in front of you.

First some history.
“Ignaz Semmelweis, a young Hungarian doctor working in the obstetrical ward of Vienna General Hospital in the late 1840s, was dismayed at the high death rate among his patients.
He had noticed that nearly 20% of the women under his and his colleagues’ care in “Division I” (physicians and male medical students) of the ward died shortly after childbirth. This phenomenon had come to be known as “childbed fever.” Alarmingly, Semmelweis noted that this death rate was four to five times greater than that in “Division II” (female midwifery students) of the ward.
One day, Semmelweis and some of his colleagues were in the autopsy room performing autopsies as they often did between deliveries. They were discussing their concerns about death rates from childbed fever.
One of Semmelweis’ friends was distracted by the conversation, and he punctured his finger with the scalpel. Days later, Semmelweis’ friend became quite sick, showing symptoms not unlike those of childbed fever. His friend’s ultimate death strengthened Semmelweis’ resolve to understand and prevent childbed fever.
In an effort to curtail the deaths in his ward due to childbed fever, Semmelweis instituted a strict hand washing policy amongst his colleagues in “Division I” of the ward. Everyone was required to wash their hands with chlorinated lime water prior to attending patients. Mortality rates immediately dropped from 18.3% to 1.3% in 1848 in Semmelweis’ division. (A)”

(1861) “…. Louis Pasteur was showing the world that microorganisms did indeed exist, that they acted on our world in myriad ways and that the ancient wisdom about “bad vapors” and spontaneous generation were wrong. Dead wrong. Prior to Pasteur and what would become known as “germ theory,” the prevailing theories held that organisms, like maggots and fleas, were spontaneously originated from other matter, like raw meat or diseased flesh…..
Pasteur is credited with opening the world’s eyes to the new science of microbiology and ushering in a brand new form of preventive medicine: immunization. …Building on what Pasteur was discovering, British surgeon Lister began to use this new germ theory to demonstrate the lifesaving value of disinfectant. Despite his skill at surgery, Lister knew that half his amputee patients would die of infection after the procedure…..
He began to treat his surgery equipment, before and after use, with carbolic acid. He also treated his patients’ wounds with it…..within two years, operative mortality decreased from nearly 50 percent to just 15 percent.” “Much of the greatness of Pasteur and Lister lies in their dogged persistence to spend 20 years convincing the rest of the medical world of the truth of their investigations,” ….. (B)

(1881) “What Dr. Towsend did next was something that Joseph Lister, despite years spent traveling the world, proving the source of infection and pleading with physicians to sterilize their hands and instruments, had been unable to prevent. As the president (Garfield) lay on the train station floor, one of the most germ-infested environments imaginable, Towsend inserted an unsterilized finger into the wound in his back, causing a small hemorrhage, and almost certainly introducing an infection that was far more lethal than Guiteau’s bullet.” (C)

“The shot in the back was not fatal, not hitting any vital organs. The bullet lodged behind the pancreas. “If they had just left him alone he almost certainly would have survived,” Millard said. Within minutes, doctors converged on the fallen president, using their fingers to poke and prod his open wounds. “Twelve different doctors inserted unsterilized fingers and instruments in Garfield’s back probing for this bullet,” Millard recounted, “and the first examination took place on the train station floor. I mean, you can’t imagine a more germ-infested environment.” American doctors at the time didn’t believe germs existed at all. And according to Dr. Jeffrey Reznick of the National Library of Medicine, they rejected the use of antiseptics pioneered by British surgeon Joseph Lister, for whom Listerine would later be named” (D)

FAST FORWARD 150 YEARS

“Hospital infections affect almost two million people in the United States every year, 100,000 of whom die. Up to 70 percent of these infections could be prevented if health care workers follow recommended protocols, which include hand hygiene….
“Why is it still so hard to get health care workers to wash their hands?
Active resisters are people who like doing things a certain way for the simple reason that things have always been done that way. During one site visit, an infectious diseases doctor involved in preventing infections told us:
Getting the surgeons to adopt things in general is problematic … they’re like baseball players, they’ve got superstitions…in their minds if it’s working, why should we change it.
But at least you know who these people are since they speak up at meetings and actively resist changing behavior.
The second type are what we termed organizational constipators. These individuals often have nothing against an initiative per se but simply enjoy exercising their power by refusing to change, albeit below the radar. The challenging aspect about organizational constipators is that the people above them think they are doing a good job, while those below them cannot believe they still have a job.
Yet another barrier we found in our research is that many hospitals have a culture of mediocrity rather than a culture of excellence. These hospitals are content to be just good enough. Leadership is generally ineffective. Overperformers are rewarded with more work.” (E)

“…this sobering truth. When bacteria lurking on, for instance, a medical device, a bed rail, a bandage or a caregiver’s hands find their way into a patient’s body via a surgical wound, a catheter, a ventilator, or some invasive procedure, the disturbingly frequent result is a serious, sometimes devastating, infection.” (F)

“Hospital-acquired infections (HAI) cost $9.8 billion per year, with surgical site infections alone accounting for one-third of those costs, followed closely by ventilator-associated pneumonia at 31.6 percent….” (G)

“Hands are the most common vehicle for transmission of organisms and “hand hygiene” is the single most effective means of preventing the horizontal transmission of infections among hospital patients and health care personnel. ” (H) (I)

“How dirty is your Qwerty?
It turns out that your computer keyboard could put a host of potentially harmful bacteria — including E. coli and staph — quite literally at your fingertips.
Sure, it may sound like a hypochondriac’s excuse to stay away from the office. But a growing body of research suggests that computer mice and keyboards are, in fact, prime real estate for germs.
It’s a phenomenon most recently illustrated by tests at a typical office environment in the United Kingdom. A consumer advocacy group commissioned the tests in which British microbiologist James Francis took a swab to 33 keyboards, a toilet seat and a toilet door handle at the publication’s London office in January.
Francis then tested the swabs to see what nasty germs he managed to pick up. He found that four of the keyboards tested were potential health hazards — and one had levels of germs five times higher than that found on the toilet seat.” (J)

“Question: I recently had an appointment with a medical specialist. I got called into the clinic room where I waited for the doctor; and I noticed a few “wash your hands” posters. When he came in, I swear he didn’t use the hand sanitizer. I couldn’t be sure. And I didn’t want to ask – but I was kind of grossed out. What should I have done? Is it okay to question the doctor about hand washing?
Answer: Your concerns about hand washing are certainly justified. Poor hand hygiene practices are largely to blame for the spread of germs within health care settings…
If you ever suspect that your doctor, nurse or other health care provider forgot to use the hand sanitizer, by all means raise the question. But, in reality, most patients in your situation are reluctant to do so.
“Very few people would ever be comfortable asking their health-care providers if they’ve cleaned their hands,” acknowledges Dr. Vearncombe. “Our patients feel very vulnerable,” she explains. “They are in an imbalanced power relationship with us, so it is really hard for them to ask.”
Indeed, some patients fear that their treatment could be jeopardized if they challenge the doctors and nurses on even routine matters such as hand hygiene. Their care will certainly not be affected, but it’s a worry for them nonetheless.
Surveys going back almost a decade found that Ontario patients didn’t want to be placed in the role of a police officer to ensure that doctors and nurses wash their hands.
As a result of these surveys, most of the hand-hygiene education in Ontario has focused on the health care providers themselves.
Since 2007-2008, Ontario hospitals have been required by provincial law to report their hand-hygiene rates. In some hospitals, such as Sunnybrook, designated staff members routinely observe interactions of health care providers with patients to track if they are actually washing their hands at the appropriate times.”
Before mandatory reporting took effect, a study carried out at a few hospitals had revealed that hand-hygiene compliance rates were “abysmally low,” notes Dr. Vearncombe.
The rate at Sunnybrook, for instance, was originally less than 40% – similar to many other hospitals. “We have made great increases in our hand-hygiene compliance, and the most recent results show our overall rate is now 87%.”..
A pilot study at Sunnybrook has been exploring what role patients could play.
Three of the hospital’s inpatient wards were selected for the pilot. As part of the study, an information card was placed on the bedside table whenever a room was cleaned and prepared for a new patient.
“This little card explained in lay language what to expect” when a health-care provider entered the patient’s room, says Dr. Vearncombe.
The cards stated that “Your care provider should clean their hands: 1) Before contact with you; 2) Before a procedure; 3) After a procedure; and 4) After contact with you.”
The cards also included the catchphrases: It’s okay to ask staff, ‘Did You Clean Your Hands?’ and Reminders help everyone!
So, the next time you suspect a health-care worker may have skipped the hand sanitizer, don’t hold back. Everyone benefits when fewer germs are spread around.” (K)

“At Denver Health Medical Center, the CenTrak monitoring system is used on two of the medical-surgical wards, the medical intensive care unit, and the step-down care unit. On these particular units, all rooms are single occupancy.
All nurses and healthcare technicians on these floors, as well as those on the float team, have badges. Additionally, select hospitalists, intensivists and residents also have badges to track their personal electronic hand hygiene adherence.
“We monitor both waterless hand sanitizer and soap dispensers,” Young explained. “We have defined adherence with the technology to be performing hand hygiene within 60 seconds before or after entering the room and within 60 seconds before or after leaving the room.”
Denver Health has used the electronic hand hygiene monitoring system as a means to both effect and measure change in hand hygiene. For example, it has used electronic hand hygiene to study the effect of poster placement on hand hygiene habits. It also has provided individual feedback to staff members on their hand hygiene rates and studied the change in electronic hand hygiene over time.
The hospital has achieved quite a success with baseline hand hygiene adherence rates nearly doubling. While Denver Health measures multiple hand hygiene workflows, this particular example of improved compliance was in regard to its wash-in/wash-out protocol – the requirement for staff to wash their hands upon entering a room and again after their interaction with a patient.
“Using data from the electronic hand hygiene compliance system, Denver Health was able to properly audit hand hygiene processes and provide additional training and education to staff where needed most,” said Young.” (L)
“The 70-page report, “Guide to Hand Hygiene Programs for Infection Prevention,” outlines an eight-step multimodal program that hospitals can follow to ensure hand-hygiene program success.
“It’s when all those components of hand-hygiene programs are working together effectively that we see the biggest change,” Timothy Landers, R.N., lead editor of the guide, said in a report announcement. However, the report makes it clear that without one component–the full support of hospital leadership–programs will continue to fail.
“Leadership’s commitment to hand hygiene must be visible and engaging–to the organization and the public through formal communication, hand-hygiene education, promotions, and event sponsorship,” the report said.
In addition to leadership support, the guide also recommends that hospitals follow these steps:
Establish ongoing monitoring and feedback on infection rates, such as tracking endemic and emerging drug resistant pathogens.
Create a multidisciplinary design and response team led by a senior administrator to emphasize that the organization is committed to hand-hygiene compliance.
Provide ongoing education and training for staff, patients, families and visitors. The report suggests the use of instructive posters, pocket cards and brochures for training.
Ensure hand-hygiene resources are accessible throughout the organization, including patient care corridors and at the entrance and exit of patient rooms.
Reinforce hand-hygiene behavior and accountability. Some organizations have success conducting contests and recognizing healthcare workers who comply with the guidelines.
Provide reminders throughout the healthcare setting. For example, the report suggests organizations provide real-time feedback from observers, coworkers, patients and visitors.
Develop an ongoing monitoring program that includes feedback. Some organizations, the report said, post monthly compliance data on hospital units or their hospitals’ Web sites and discuss the findings with staff during meetings.” (M)

“Most evaluation reviews are generated after a major, life-threatening error occurs, which usually happens infrequently. Historically, when an evaluation determined that a process completed by personnel was deficient, problem-solving efforts focused on the identification of the specific individual(s) who “caused” the problem. Later, quality improvement efforts focused on developing a culture of safety and recognized that additional contributions to errors were due to complex, poorly designed systems. The advantage of an evaluation that reviews system problems is that it encourages health care professionals to report adverse events and near misses that might be preventable in the future, while balancing the identification of system problems with holding individual providers responsible for their everyday practices. Improvement is impossible without evaluation reports to provide data on the factors that contribute to mistakes and lead to subsequent individual and system changes that support safer practices.
An evaluation strategy examining process measures include the following examples:
Document staff use of maximum sterile barriers (cap, mask, sterile gown, sterile gloves, large sterile sheet) and aseptic technique for the insertion of central intravenous catheters or guidewire exchange.
Document timing of antibiotic prophylaxis when used in surgical patients (e.g., within 1 hour of incision).
Document if hand hygiene is performed and clean or sterile gloves are worn before assessing a catheter insertion site or changing a dressing on intravascular catheters.
Document time elapsed from when patient culture (microbiology and susceptibility) results are reported and when the appropriate isolation precautions are instituted (patient room placement, signs, PPE used, disposable equipment used, medical record documentation, etc.).
Ensure that staff (nurses, doctors, and housekeeping) enter a contact isolation room using the specified personal protective barriers (e.g., gloves, gown) on each entry.
Ensure that staff properly remove PPE after leaving a patient’s room.
Assess the annual rates of influenza vaccination for health care workers and other personnel eligible to receive vaccination; assess the rates of influenza vaccination for patients.
Ensure that needle disposal containers are no more than three-quarters full at time of disposal.
Periodically monitor and record adherence with the hand hygiene guidelines: the number of times personnel washed their hands divided by the number of hand-hygiene opportunities, computed by ward or by service. Provide feedback to personnel regarding their performance.
Monitor the volume of alcohol-based hand rub (or detergent used for handwashing or hand antisepsis) used per 1,000 patient days.
When outbreaks of infection occur, assess the adequacy of health care worker hand hygiene.
When a patient with a known colonization or infection with a multidrug-resistant organism (e.g., MRSA, VRE) is transferred to your facility, evaluate effectiveness of system notification to health care personnel in the receiving facility.
Record compliance with hospital policy for catheter-site dressing changes.” (N)

“Hospitals have several different options to consider when monitoring compliance.
• Direct observation: This method involves monitoring the actual hand hygiene actions of staff. It can be done manually – with an actual person doing the monitoring – or it can be done with the assistance of technology such as smartphone apps. The smartphone apps can improve the likelihood of making covert observations and reduce the instances of Hawthorne effect, which is a social occurrence in which individuals alter or improve their behavior in response to their awareness of being observed.
• Measuring product use: This is an indirect way of conducting observations by quantifying the amount of soap and sanitizer used. Mathematical models can be used to determine how many hand hygiene opportunities there were versus how often staff actually took advantage of these opportunities.
• Electronic monitoring: Several different types of sensors are now available to measure handwashing compliance. While they can be expensive, a major benefit of electronic monitoring is it can provide administrators with real-time feedback on compliance prior to a healthcare worker’s interaction with patients.” (O)

“More than 5,200 nurses and other caregivers in 71 units at 42 hospitals across multiple states were given a radio frequency identification (RFID) badge that recorded when they triggered the ubiquitous sanitizer dispensers typically placed near the entrance to a room. Researchers monitored the tracking for as long as three and half years, ending in August 2013. There were an estimated 20 million hand-washing opportunities to study. The researchers focused on “total daily usage per unit bed,” a calculation in which the number of times total dispensers in a given hospital unit were used each day was divided by the number of beds in that unit.
Nice Start…
Personal tracking did indeed trigger an initial improvement. The daily usage of dispensers jumped from an average of 28.4 times per day in the 17 days before the tracking commenced, to 46 times a day at launch. Workers who did not receive a badge did not show any change in hand-washing habits.
…But No Sustained Momentum
Hand-washing continued to improve for more than a year and a half, but then peaked at month 20. As the graph above shows, three years into the project, usage had backslid to where it was in the first month.
That said, the researchers calculate that it would be a full 10 years of waning compliance before hand hygiene habits fell to where they were before the monitoring program was introduced – though a sub-50 compliance rate is no one’s idea of optimal.
Clearly, technology in a vacuum is not the solution. “Managers cannot simply ‘monitor and forget,'” the researchers wrote. “There is a need for ongoing managerial interventions to sustain the benefits of monitoring.” (P)

“HyGreen Inc., Gainesville, Fla., provides just-in-time coaching to health care workers when they forget to wash, and records the information in real time, says Elena Fraser, vice president of sales and marketing. “The instant the health care worker dispenses the hand wash, both the light-emitting diode on the top of the HHCM sensor and the badge turn green. At the same time, a wireless signal documents the worker identification, time and location and sends that information to the database,” she explains.
When the health care worker steps into a zone that is created by a monitor over the patient bed, the monitor recognizes that the badge is green. Again, time, location and worker ID are transmitted to the database. If the health care worker forgets to wash his or her hands, the bed monitor will cause the badge to vibrate, which serves as a subtle reminder.” (Q)

“Vanderbilt already had a traditional hand-hygiene program in place, but it was doing little to improve hand-washing rates. So the doctors took a different approach, focusing on three important areas:
Training. Every single hospital employee received training on correct hand-washing protocol, from clerical workers to chief surgeons. The training program placed much of its focus on the direct link between hand-washing and hospital-acquired infections.
Communication. Peer-to-peer communication was key to making the program work. Staff members were encouraged to speak up and remind each other of correct hand-washing practices if they noticed lapses. If someone received a reminder, the only correct response was “Thank you.”
Shared accountability. All staffers were held equally accountable for their unit’s success with achieving high hand-washing rates, even if they were visiting surgeons. Designated employees were tasked with monitoring how closely everyone followed established protocols, and units that didn’t meet established targets were encouraged to boost their performance as a whole. Staffers were also rewarded based on their collective performance in improving hand-washing rates.” (R)

“The My 5 Moments for Hand Hygiene approach defines the key moments when health-care workers should perform hand hygiene.This evidence-based, field-tested, user-centred approach is designed to be easy to learn, logical and applicable in a wide range of settings. This approach recommends health-care workers to clean their hands; before touching a patient; before clean/aseptic procedures; after body fluid exposure/risk; after touching a patient, and; after touching patient surroundings.” (S)

Few scientific studies have evaluated measurement techniques; a recent review of the reliability and validity of hand hygiene measures found that only 28% of research articles and guidelines related to hand hygiene measurement included any mention of reliability or validity. Methodology between studies varies a great deal, including how adherence or non-adherence is defined and how observations are carried out; in addition, sufficient details concerning the methods and criteria used are often lacking.
The following are some of the specific challenges to measuring hand hygiene adherence: • Contact with patients and their environment takes place in many locations within organizations. • Opportunities for hand hygiene occur 24 hours a day, 7 days a week, 365 days a year and involve both clinical and nonclinical staff. • The frequency of hand hygiene opportunities varies by type of care provided, unit, and patient factors. • Monitoring is often resource intensive; infection preventionists, quality improvement staff, and other health care workers (for example, nursing, respiratory therapy) face numerous competing demands for their time and expertise. • Observer bias (such as the Hawthorne effect) is difficult to eliminate.” (T)

It’s a simple enough request, but for patients and families who feel vulnerable, scared or uncomfortable in a hospital room, the subject can be too intimidating to even bring up with a doctor or nurse: Have you washed your hands?
Hospitals are encouraging patients to be more assertive, amid growing concern about infections that are resistant to antibiotics.
Strict hand hygiene measures are the gold standard for reducing infections associated with health care. Acquired primarily in hospitals but also in nursing homes, outpatient surgery centers and even doctor’s offices, they affect more than one million patients and are linked to nearly 100,000 deaths a year, according to the Centers for Disease Control and Prevention.
The CDC aims to engage both patients and caregivers in preventing dangerous hospital infections. Centers for Disease Control.
Yet despite years of efforts to educate both clinicians and patients, studies show hospital staff on average comply with hand-washing protocols, including cleansing with soap and water or alcohol-based gels, only about 50% of the time. (U)

(2013) “At North Shore University Hospital on Long Island, motion sensors, like those used for burglar alarms, go off every time someone enters an intensive care room. The sensor triggers a video camera, which transmits its images halfway around the world to India, where workers are checking to see if doctors and nurses are performing a critical procedure: washing their hands.” (V)

(2012) “But there are skeptics. “Another potential issue with the video observation is a false accusation of failure to wash. Patient rooms and patients themselves are not being watched. Let’s say a nurse went into a patient’s room to tell him something and didn’t touch anything. A person in India watching a video from a camera focused on a door or sink would not be able to tell that. If the nurse doesn’t wash her hands when she leaves the room, is she going to be cross-examined? (W)

“Healthcare can benefit from the power of cameras to improve accountability,” Makary, Pawlik and Xu conclude. “In an era where 86% of nurses report having recently witnessed disruptive behavior at work, hand washing compliance remains highly variable, and many physicians do not use evidence based medicine, recorded video can be an invaluable quality improvement tool. If concerns about consent, privacy, and data security are dealt with carefully, video data can tell a story that simply cannot be matched by written documentation.” (X)

(A) http://www.sciencecases.org/childbed_fever/childbed_fever.asp
(B) http://www.hhnmag.com/articles/6647-throwback-thursday-pasteur-lister-and-the-dawn-of-germ-theory
(C) DESTINY OF THE REPUBLIC, 2011
(D) How doctors killed President Garfield, https://www.cbsnews.com/news/how-doctors-killed-president-garfield/2/
(E) Hand Washing Stops Infections, So Why Do Health Care Workers Skip It?, by Sanjay Saint, https://labblog.uofmhealth.org/industry-dx/hand-washing-stops-infections-so-why-do-health-care-workers-skip-it
(F) What Zero Looks Like: Eliminating Hospital-Acquired Infections, http://www.ihi.org/resources/Pages/ImprovementStories/WhatZeroLooksLikeEliminatingHospitalAcquiredInfections.aspx
(G) Hospital-acquired infections rack up $9.8B a year, by Julie Bird, http://www.fiercehealthcare.com/healthcare/hospital-acquired-infections-rack-up-9-8b-a-year
(H) Guidelines for prevention of hospital acquired infections, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963198/
(I) Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene, http://www.jstor.org/stable/10.1086/677145
(J) Your Keyboard: Dirtier Than a Toilet, by Dan Childs, https://abcnews.go.com/Health/Germs/story?id=4774746&page=1
(K) It’s okay to ask your doctor: “Did you wash your hands?”, by Paul Taylor, http://healthydebate.ca/personal-health-navigator/okay-ask-doctor-wash-hands
(L) Denver hospital deploys hand hygiene monitoring system to boost adherence, by Bill Siwicki, https://www.healthcareitnews.com/news/denver-hospital-deploys-hand-hygiene-monitoring-system-boost-adherence
(M) An 8-step strategy to improve hand-hygiene, by Ana Mulero, https://www.fiercehealthcare.com/healthcare/8-step-strategy-to-improve-hand-hygiene-compliance
(N) Chapter 41Preventing Health Care–Associated Infections, by Amy S. Collins, https://www.ncbi.nlm.nih.gov/books/NBK2683/
(O) A culture of support: 4 ways to improve hand hygiene compliance, by Brian Zimmerman, https://www.beckershospitalreview.com/quality/a-culture-of-support-4-ways-to-improve-hand-hygiene-compliance.html
(P) Hospital Hand Washing: The Limits of Electronic Monitoring, by Carla Fried, https://www.anderson.ucla.edu/faculty-and-research/anderson-review/hand-washing
(Q) Hand hygiene monitoring, by Neal Lorenzi, https://www.hfmmagazine.com/articles/1348-hand-hygiene-monitoring
(R) Hand washing: How one hospital achieved nearly 100% compliance, by Jess White, http://www.healthcarebusinesstech.com/hospital-hand-washing/
(S) My 5 Moments for Hand Hygiene, World Health Organization
(T) MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES, https://www.jointcommission.org/assets/1/18/hh_monograph.pdf
(U) https://www.wsj.com/articles/why-hospitals-want-patients-to-ask-doctors-8216have-you-washed-your-hands8217-1380582268
(V) https://www.news-medical.net/news/20130530/Hospitals-cracking-down-on-those-who-dont-wash-their-hands.aspx
(W) https://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html
(X) (X) https://www.bing.com/search?q=Healthcare+can+benefit+from+the+power+of+cameras+to+improve+accountability%2C%E2%80%9D+Makary%2C+Pawlik+and+Xu+conclude.+%E2%80%9CIn+an+era+where+86%25+of+nurses+report+having+recently+witnessed+disruptive+behavior+at+work%2C+hand+washing+compliance+remains+highly+variable%2C&form=EDGNB2&mkt=en-us&httpsmsn=1&refig=5a97bb2eab724efaa4bfa43d68002018&sp=-1&pq=&sc=8-0&qs=n&sk=&cvid=5a97bb2eab724efaa4bfa43d68002018