Internal jugular catheters may be left in place for up to three weeks without a high risk of bacteremia, but femoral catheters in bed-bound patients should be removed after one week. Catheter exchanges over a guidewire for catheter malfunction do not increase bacteremia rates. Temporary catheters should be removed immediately if an exit site infection occurs.

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Physicians are notorious for poor hand hygiene (HH) compliance. We wondered if lower performance by physicians compared with other health professionals might reflect differences in the Hawthorne effect. We introduced covert HH observers to see if performance differences between physicians and nurses decreased and to gain further insights into physician HH behaviors. Following training and validation with a hospital HH auditor, 2 students covertly measured HH during clinical rotations. Students rotated off clinical services every week to increase exposure to different providers and minimize risk of exposing the covert observation. We compared covertly measured HH compliance with data from overt observation by hospital auditors during the same time period. Covert observation produced much lower HH compliance than recorded by hospital auditors during the same time period: 50.0% (799/1597) versus 83.7% (2769/3309) (P < 0.0002). The difference in physician compliance between hospital auditors and covert observers was 19.0% (73.2% vs 54.2%); for nurses this difference was much higher at 40.7% (85.8% vs 45.1%) (P < 0.0001). Physician trainees showed markedly better compliance when attending staff cleaned their hands compared with encounters when attending did not (79.5% vs 18.9%; P < 0.0002). Our study suggests that traditional HH audits not only overstate HH performance overall, but can lead to inaccurate inferences about performance by professional groupings due to relative differences in the Hawthorne effect. We suggest that future improvement efforts will rely on more accurate HH monitoring systems and strong attending physician leadership to set an example for trainees. Journal of Hospital Medicine 2016;11:862-864. Hand hygiene (HH) is believed to be one of the single most important interventions to prevent healthcareassociated infection, yet physicians are notorious for their poor compliance. 1-3 At our 800-bed acute care academic hospital, we implemented a multifaceted HH program 4 in 2007, which was associated with improved HH compliance rates from 43% to 87%. Despite this improvement, HH compliance among physicians remained suboptimal, with rates below 60% in some patient areas. A targeted campaign focused on recruitment of physician champions, resulted in some improvement, but physician compliance has consistently remained below performance of nurses (70%-75% for physicians vs 85%-90% for nurses).Our experience parallels the results seen in multinational surveys demonstrating consistently lower physician HH compliance. 5 Given the multiple improvement efforts directed at physicians and the apparent ceiling observed in HH performance, we wanted to confirm whether physicians are truly recalcitrant to cleaning their hands, or whether lower compliance among physicians reflected a differential in the Hawthorne effect inherent to direct observation methods. Specifically, we wondered if nurses tend to recognize auditors more readily than physicians and therefore show higher apparent HH compliance when auditors are p...

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