Preventing Infection Through Handwashing
By Ruth LeTexier, RN, BSN, PHN
In the healthcare setting, handwashing is often cited as the primary weapon in the infection control arsenal. The purpose of handwashing in the healthcare setting is microbial reduction in an effort to decrease the risk of nosocomial infections.
Hand hygiene can also be a problem in busy health centers and clinics where patients are seen both in increasing numbers and treated in rapid succession.1 Prevention and control of infectious activities are designed to limit the spread of infection and provide a safe environment for all patients, regardless of the setting.2 In light of the emergence of antibiotic resistant organisms, effective infection control measures, such as handwashing, are essential to prevention.
At a recent Global Consensus Conference, participants were charged with the overall purpose of achieving consensus on infection control practice across healthcare settings and international boundaries related to caring for patients with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE). The conference provided a major opportunity for professionals and scientists in the infection and prevention control field to discuss trends and develop strategies for best practice. The aim was to examine the infection control problems associated with these antibiotic-resistant organisms (AROs) and to consider possible solutions.3 One estimate places the direct cost of nosocomial infections caused by six different strains of AROs to be minimally $1.3 billion (1992 dollars)/year in the US.4 According to the Center for Disease Control and Prevention (CDC), each year an alarming 2,400,000+ nosocomial infections occur in the US alone. They are estimated to cause directly 30,000 deaths and contribute to another 70,000 deaths each year. Nosocomial infections cost over $2,300 per incident and $4.5 billion annually in extended care and treatment.
The goal of the Global Consensus Conference was to focus on specific issues that come under the direct influence of infection control professionals. Among the issues of focus was hand hygiene. Participants in the conference started with the premise that the ultimate goal of cleansing the skin of care providers, regardless of specific product used, is to prevent the transmission of infection, including AROs, from their hands. Skin workshop final recommendations included:
1. Hand hygiene is the single most important procedure for preventing the transmission of AROs.
2. Evidence suggests that the removal of AROs from hands with soap/detergent and water is less effective than with the application of an antiseptic agent.
3. An antiseptic product shall be used in high-risk areas, with high-risk patients, and with known ARO patients. High risk areas may include:
- Intensive care units
- Transplant units
- Burn units
- Hematology/oncology units
- Hemodialysis units
- Patients at risk were identified as those:
--Receiving multiple antibiotics or repeated treatments
--With prolonged hospital stay
--With frequent admissions
4. High-risk areas and high-risk patients shall be identified by regular assessment.
5. Risk assessment for acquisition/transmission of AROs may include patient surveillance cultures.
6. In the absence of sufficient handwashing facilities and where there is no visible soil on the hands, an antiseptic product formulated for use without water shall be used. In the absence of sufficient or adequate handwashing facilities where there is visible soil on the hands, soil must first be removed by some means (e.g., rinsing, mechanical, rubbing, and wipes) before use of an antiseptic product formulated for use without water.3
The CDC has identified handwashing as the single most important means of preventing the spread of infection.5 The premise of the handwashing CDC guideline is infection control. The CDC recommendations for handwashing are as follows:
In the absence of a true emergency, personnel should always wash their hands:
1) Before performing invasive procedures (Category I).
2) Before taking care of particularly susceptible patients, such as those who are severely immunocompromised and newborns (Category I).
3) Before and after touching wounds, whether surgical, traumatic, or associated with an invasive device (Category I).
4) After situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood or body fluids, and secretions or excretions (Category I).
5) After touching inanimate sources that are likely to be contaminated with virulent or epidemiologically important microorganisms; these sources include urine-measuring devices or secretion collecting apparatuses (Category I).
6) After taking care of an infected patient or one who is likely to be colonized with microorganisms of special clinical or epidemiologic significance, for example multiple-resistant bacteria (Category I).
7) Between contacts with different patients in high-risk units (Category I).
For routine handwashing, a vigorous rubbing together of all surfaces of lathered hands for at least 10 seconds, followed by thorough rinsing under a stream of water is recommended (Category I).
The aim of handwashing is to remove microorganisms from the hands, preventing their potential transfer. It is known that organisms survive and multiply on human hands, creating the opportunity to infect others or the host.6 Handwashing reduces the number of transient organisms on the skin surface. Although hands cannot be sterilized, most transient organisms can be removed by 30 seconds of proper scrubbing with soap and water. Proper scrubbing would include vigorous motion with the hands rubbing together and fingers working in between the finger web space and inclusive of the dorsal and ventral surfaces of the hands. Microbes that reside in sweat ducts and hair follicles of the skin, however, cannot be dislodged readily. Surveys show that one in five medical professionals carry potentially pathogenic antibiotic-resistant pathogens on his or her hands. Handwashing by medical professionals occurs at only 30% of the ideal rate. Failure to wash one's hands before and after each patient contact is probably the most important contributor to the spread of infections.7 These microbes pose a threat to patients with reduced defenses, so scrubbing with an antiseptic prior to contact with these patients is usually recommended.
In one study, hospital-acquired infections were reduced 25% by handwashing with soap plus antiseptic compared to a control group who washed with soap alone.7 The absolute indications for handwashing with plain soaps and detergents versus handwashing with antimicrobial-containing products are not known because of the lack of well- controlled studies comparing infection rates when such products are used.5
The effects of handwashing in the prevention of disease transmission from person to person are undeniable; however, the goal of effective compliance remains unmet.
Education and training of staff has been a central focus of infection control programs with marginal impact. Compliance testing devices may spark awareness in the healthcare work force. The effects of verification and feedback as a mechanism for increasing the probability of handwashing in the clinical setting appear to be quite dramatic. Compliance Control Center (Forestville, Md) conducted a study with the intent to measure the impact of individual measurement and verification of overall handwashing compliance. At each location, each individual employee for whom handwashing was deemed critical to the prevention of infection and cross contamination either chose or was assigned an individual and unique verification number to be used with the Compliance Control electronic handwashing verification system (e.g., HyGenius) throughout the study. In each of the locations, despite the fact that both supervisors and employees expressed that they believed they were doing a good job of handwashing, in actuality, observed handwashing frequency was low during the observation period. The overall average was 68 handwashing events per location per week, which resulted in an average of less than one handwash per day per employee.
During the next phase or pre-reporting phase, a time in which the electronic devices were installed, handwashing frequency increased by an average of 214% going from 68 in the assessment phase to 213.63% in the pre-reporting phase. The results were likely due to the fact that a means for handwashing measurement requiring individual employee self-identification was introduced at each site. For a period of 35 weeks, a sustained average of 603 handwashes per week was performed in the study locations. On average, through the conclusion of the reporting period, there was an 890% handwashing rate increase over the initial observation period measurements. This study indicates that reinforcement and regular performance feedback using empirical data significantly improves handwashing compliance.8
While the healthcare worker may have the convincing data or argument for handwashing as an infection control preventive activity, handwashing remains an activity of self-monitoring. Barriers to effective monitoring may be related to education, level of awareness, the development of an aseptic conscience, lack of motivation, lack of facilities such as access to sinks, soap, antibacterial detergents, time, etc. If one accepts handwashing as the primary weapon in the infection control arsenal, then personal choice for handwashing rests with the individual foot soldier in the battle against the transmission of infection or disease.
Ruth A. LeTexier, RN, BSN, PHN, is a nurse educator and Program Director of Surgical Technology at Northwest Technical College (East Grand Forks, Minn).
1 Gould DJ. Giving infection control a big hand. Community Nursing Notes. 1997;15:3-6.
2 Stucke VA. Microbiology for Nurses: Application to Patient Care. 7th ed. London: Bailliere Tindall.
3 Global consensus conference: final recommendations. AJIC. 1999;27:503-513.
4 US Congress Office of Technology Assessment. Impacts of Antibiotic Resistant Bacteria. OTA-H-629. Washington (DC): US Government Printing Office; 1995 September.
5 Garner JS, Favero MS. CDC guidelines for the prevention and control of nosocomial infections. Guideline for handwashing and hospital environmental control. AJIC. 1986;14(3):110-115.
6 Reybrouck G. The role of hands in the spread of nosocomial infection. J Hosp Infect. 1983;90,30,63-64.
7 McKane L, Kandel J. Microbiology Essentials and Application. 2nd ed. McGraw-Hill; 1996:362;683.
8 Compliance Control Center website: http://users.aol.com/comontrol/cci4.htm.
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