Infection Control Today - 03/2004: Handwashing and Cross Contamination

Handwashing and Cross Contamination:
Old Issue, New Approaches

By Kelly M. Pyrek

With numerous hand-hygiene studies in the literature, theres plenty of data confirming what we already know actual handwashing compliance (and not just self-reported incidences) is 30 to 50 percent.1 Also well documented is the role handwashing plays in cross contamination a source of hospital acquired infections.

Some experts recognize that efforts to increase handwashing episodes must be focused on changing actual healthcare worker (HCW) behavior, not simply improving their knowledge of handwashing requirements.

With the new alcohol products, hand hygiene will be more of a behavioral issue and less of a time or convenience issue than it has been in the past, says Elaine Larson, RN, PhD, FAAN, CIC, associate dean and professor of pharmaceutical and therapeutic nursing at Columbia University.

Researchers are paying more attention to the link between habit formation and behaviors such as handwashing. Studies of human brain development show that new neural connections continue to form and old connections are strengthened because of repeated thoughts or behaviors. Neural connections that get used tend to last, while those that are not reinforced fade away the use it or lose it principle at work.

Researchers say learning that makes use of repetition tends to be ingrained deeper and more permanently in the brain, and that the carving of these mental pathways helps form the individuals behavioral matrix. You might be able to teach an old dog new tricks after all, since old neuron pathways can be reactivated; the key is behavior modification. However, the biggest challenge might be addressing individuals resistance to change. Most people change only if they want to change, because the status quo is comfortably familiar and safe. Brains become wired to adopt the same behavior, so if someone does not wash his or her hands, he/she may not change their habits unless behavioral interventions are implemented.

In 2000, a team of researchers led by Larson published research into behavioral aspects related to handwashing.2 They first answered the question of how much handwashing is enough, and whether more frequent or better handwashing had an incremental impact on the reduction of risk of hospital-acquired infections. They concluded, Even in this era of multiple precautions, several studies in the 1990s have demonstrated that staff handwashing led to a measurable positive effect on nosocomial infection rates. Hence, continued emphasis on handcare regimens seems justified. If that is the case, however, another challenge that of the handwashing behavior of healthcare professionals has proved to be stubbornly resistant to intervention and change.

Organizational culture may be to blame, says Dion Lerman, CFSP, education and training director for The Handwashing Leadership Forum in Philadelphia. He points to researchers Sturges and Minor, who say that organizational culture has two aspects formal and informal.3 Formal aspects, such as mission statements, policies, procedures and rules, are what supervisors expect to enforce and thereby change behavior. It is the informal aspects such as values, norms and assumptions that have more impact on employees and are much more difficult to change.

Everything from peer pressure to social mores can come into play to affect hand-hygiene compliance. If a healthcare facility has created a culture that embraces handwashing as the right thing to do for its patients and its employees, chances are it is more effective than a culture that leaves hand hygiene as an afterthought. Do physicians wash their hands and set a good example for medical students? Do nurses wash their hands to set a good example for nursing assistants? Are dietary and housekeeping personnel given the same opportunities for education about proper hand hygiene?

Does management provide all departments with the resources they need to encourage and reward hand hygiene? Many times, there is also a dichotomy between knowledge and behavior. Knowledge itself does not change behavior, said researcher Don Kirkpatrick in the 1950s. Educator Benjamin Bloom suggested that education needed to embrace three processes in order to be effective: cognitive (knowledge-oriented); affective (emotionoriented); and psycho-motor (skill-oriented).

For supervisory personnel, cognitive processes about handwashing may be sufficient, but for those at the operational level, it may be necessary to address motivation and skill issues. Lerman describes elements of a classic learning theory:3

  • Unconscious incompetence is the ignorance of poor behavior
  • Conscious incompetence is the teachable moment during awareness of bad behavior
  • Conscious competence is the learning and practice of new behavior
  • Unconscious competence is the internalization and performance of new behavior

This model dictates that the culture itself must be changed, because within the context of the existing culture, the current behavior is appropriate. Lerman says, Culture does not change by mandate, but through the substitution of a new value system that is comprehensive and integrated. He adds that a successful transformation must replace:

  • Tradition with innovation (willingness to learn and adopt new behaviors)
  • Hierarchy with teamwork (replacing rigidity with a cooperative respect)
  • Anti-authoritarian reaction with empowerment (taking proactive responsibility)
  • Endurance with persistence (using technology to remove some of the physical labor)

The Handwashing Leadership Forum suggests the following tips to accomplish good handwashing behaviors:

  • Resources should be designed to communicate cross-culturally, using visual, not verbal techniques
  • Resources produced to change worker behavior must consciously model the desired traits and behavior within a context that is clearly a real-life situation
  • Concrete, rather than abstract concepts and examples should be presented; the direct effect of lack of handwashing and infections on workers, their families, patients and communities must be demonstrated
  • Personal responsibility should be reinforced
  • Assumptions about the level of workers knowledge should be avoided
  • Workers should be depicted as solving problems themselves, rather than under the direction of a supervisor or outside authority

In her 2000 paper, Larson reported, In 15 studies designed to improve handwashing, gloving, and universal precaution practices among healthcare professionals, interventions included various educational strategies, performance feedback, and environmental controls or modifications, but only two of the studies reported any sustained behavioral effects on rates of infection.2

Larson found that supervisors and their organizations culture can be more influential than expected. She writes, Despite reinforcement and monitoring by hospital leadership, the intensity of implementation and commitment to components of the intervention varied in the hospital across units and departments (depending upon individual leaders) and over time. Despite this, the major components of the intervention (i.e., the integration of a handwashing performance competency for all staff, and continued, visible administrative support for handwashing and other infection control practices) have become an integral part of the organizational climate and are continuing.

In Larsons study, the investigators wanted to determine if involving toplevel management in an administrative intervention that emphasized the creation of an organizational culture in which handwashing was a clear administrative expectation, would have an impact on handwashing compliance. The study was conducted at two 250-bed hospitals in the same metropolitan area, and both facilities employed a full-time infection control practitioner (ICP) responsible for surveillance of nosocomial infections and staff education. Although the handwashing intervention was hospitalwide, logistics necessitated measuring handwashing frequency in an adult ICU and neonatal ICU. Undetectable counting devices were placed inside every soap dispenser on four units, and each time the soap was dispensed, the device was triggered to record one count. An independent data collector recorded the readings from all counters on a routine basis and the counters were reset after each reading. Handwashing frequency was measured at baseline, implementation and follow-up.

Implementation of the intervention was guided by Scheins behavioral framework4 through the use of five mechanisms: attention, reaction to crises, role modeling, allocation of rewards, and criteria for selection and dismissal. For the intervention, top managers and medical/nursing leaders (including the CEO, vice president of nursing, hospital board and medical staff board) agreed to provide active support for a culture change that highlighted and enforced expectations for handwashing compliance. Twenty managers were identified as clinical leaders who would develop and oversee the intervention, and from that, a smaller group met with the study researchers to identify specific interventions and strategies that aligned with Scheins mechanisms. They are:

  • Attention: Leaders communicate their values and concerns by their choices for praise or criticism (i.e., a letter from the CEO stating the facilitys commitment to handwashing; a handwashing fact sheet is developed and distributed to all employees; an article describing proper hand hygiene protocol is published in the facility newsletter; samples of hand-hygiene products are distributed; infection-rate data is distributed)
  • Reaction to crises: Leaders can reinforce values and desired behaviors in times of crisis to increase the potential for organizational learning (i.e., outbreaks of VRE and MRSA above the facility threshold are used as opportunities to review and reinforce handwashing)
  • Role modeling: Leaders communicate values by their own actions (i.e., handwashing by leaders is visible to all employees)
  • Allocation of rewards: Leaders communicate values by the selection of individuals for formal recognition (i.e., handwashing competency is recognized and rewarded)
  • Criteria for selection and dismissals: Leaders make explicit the behaviors expected by favoring those in compliance and dismissing those who are not (i.e., all new hires receive and sign a copy of the handwashing fact sheet and receive sample handhygiene products)

The counting devices recorded 860,567 handwashes during eight months of monitoring; 477,680 in the intervention hospital and 382,887 from the comparison facility, and handwashing frequency increased at both facilities (the number of soap-dispensing episodes increased from 42.6 per patient-care day to 116.6 during the follow-up stage). A total of 236,989 patient-care days were monitored; records showed 29 nosocomial infections with VRE and 44 with MRSA in one hospital and 80 VRE/55 MRSA in the other hospital. The study showed no significant differences in MRSA rates between the hospitals during either the implementation or the follow-up phases, but the intervention hospital showed significantly lower rates of VRE during both implementation and follow- up. Rates of MRSA from baseline to follow-up in the intervention hospital showed a 33 percent decrease and a 31 percent increase in rates in the comparison hospital. Rates of VRE decreased 85 percent in the intervention hospital from baseline to follow-up rates and decreased 44 percent in the comparison hospital. In the intervention hospital, no outbreaks of VRE or MRSA were detected throughout the study period, while the comparison hospital experienced two outbreaks.

Larsons team acknowledges a survey5 showing that 1,716 healthcare workers thought that the No. 1 predictor of adherence to universal precautions was a safety climate in the facility, including a strong and overt management commitment to safety, as well as formal training. Larsons team says it believes in a trickle-down effect. We undertook this study because we became persuaded by the evidence that any intervention that is aimed primarily at the individual practitioner to the exclusion of the organization, even if it is grounded in sound behavioral science theory and is well designed, will not produce cost-effective, sustainable results.

The investigators emphasized that handwashing in the intervention hospital did not increase immediately, only to die off quickly; instead, changes were modest but continued and increased over time. Its a buy-in pattern, the researchers said, indicative of an organizationwide diffusion that becomes sustained as cultural norms are modified.

They summarized, Influencing habitual behaviors, such as handwashing, is extremely difficult and has proven to be a resistant challenge in healthcare settings. In this study, we found a temporal association between an organizational intervention and changes in estimated handwashing frequency and infection rates. If these results are repeated in other settings with rigorous methods and formal, randomized clinical trials, this simple intervention could offer new hope for a highly intractable problem. The results of this study, which point to a significant and sustained increase in frequency of handwashing with a concomitant reduction in rates of VRE and MRSA, are sufficiently promising to warrant further study in other settings. Interventions directed toward changing organizational culture and expectations may offer a successful approach to both improved handwashing and other clinical practices.

In a paper that predated the behavioral intervention project, Larson spearheaded a year-long clinical trial in an ICU that was designed to increase the frequency of handwashing through use of multifaceted interventions.6 While significant improvements were noted on the unit during the study, Larson reported that within two months, handwashing practices had returned to baseline, despite intensive and ongoing efforts to address the components of the behavioral change model: predisposing (knowledge, beliefs, attitude); enabling (skills, equipment); and reinforcing (peer support, feedback). The intervention was not only very expensive and labor intensive; it was also ineffective and shortlived, she wrote.

Larsons team acknowledged, Mounting evidence indicates that behavioral interventions, even when based on sound social science theory, may have only a limited effect on ingrained public habits, such as hand hygiene.

In this paper, Larson and three other researchers studied predisposing, enabling, and reinforcing factors to improve frequency of handwashing. Over the course of a year, multifaceted interventions including focus group sessions, installation of automated sinks, and feedback to staff on handwashing frequency were implemented in an ICU. Variables observed were handwashing frequency and self-reported practices and opinions about handwashing. During 301 hours of observation, 2,624 handwashings were recorded. The proportion of times hands were washed varied by indication, ranging from 38 percent before invasive procedures to 86 percent for dirty-toclean procedures (p < 0.00001). The researchers concluded, Although there were some significant differences between experimental and control units in handwashing during the study, these differences had returned to baseline by the two-month follow-up. There were no significant differences in self-reported practices and opinions from before to after intervention, nor between units. Intensive intervention, including feedback, education, and increased sink automation, had minimal long-term effect on handwashing frequency.

In 1998, Larson and Edna Kretzer, RN, MS, CFNP published a paper7 that studied several behavioral theories within the context of HCW behavior. They wrote, Compliance is the degree to which a person adheres to advice. Healthcare workers have cited various reasons for noncompliance with handwashing and use of barrier precautions: insufficient time, inaccessible handwashing supplies, irritating handwashing agents, lack of knowledge of protocols, forgetfulness, interference with provider/patient relationships, altered tactile sensation, and restriction of movement. Noncompliance with universal precautions has been reported to be significantly correlated with sex (male healthcare workers are less compliant), worker perception of patient needs, highly risk-taking personality, and the safety climate of the institution. Compliance is also associated with certain sociodemographic and attitudinal factors, such as profession, type of clinical setting, and geographic location. They continued, At the group level, active involvement and encouragement from key staff members may help to promote and sustain behavioral changes in healthcare settings. Furthermore, administrative sanctions and leadership have been associated with improved compliance rates. This suggests that both external (environmental) and internal (personal) variables must be considered when planning interventions to improve compliance.

These theories can help healthcare professionals understand behavioral triggers:

  • The Health Belief Model (HBM) says that ones actions depend on the perceived susceptibility to a health threat, the perceived severity of the threat, and the belief that a particular health recommendation would be beneficial without risk. For example, one would adhere to universal precautions if one believed that no one was susceptible to a serious infection during a patient interaction and expected to contract the infection if no protective measures were taken; cues in the environment would trigger use of these measures. For example, the individual may ask, Am I aware that a threat to my health exists if I fail to wash my hands regularly? while the organization may ask, Do we understand the relationship between handwashing and spread or risk of infection?
  • The Theory of Reasoned Action (TRA) and the Theory of Planned Behavior (TPB) are based on the assumption that humans are rational, make systematic use of information, and consider the implications of their actions before engaging in a behavior. The theory suggests that one who believes that a behavior will lead to a positive outcome will hold a favorable attitude toward it.
  • Self-efficacy is defined as a persons judgment of their capability to organize and execute courses of action required to attain types of performances. It can be influenced by attainment, observatory experiences, verbal persuasion and physiological state. Thus, personal perception accounts for the effort and persistence applied to a specific behavior. The individual may ask, Do I believe that I can contribute to the reduction of infection? while the organization may ask, Do we wash as frequently as expected and as carefully as prescribed?

The researchers say, No behavioral theory has been shown to consistently predict behavior, but many theories share similar constructs that could be integrated into an intervention to improve infection control practices. The key is understanding what the individual might be thinking, and whether or not that thought is aligned with the facilitys values. Individuals may think, I might wash my hands more frequently if my efforts were supported. Do I value the reduction of infection enough to be committed to changing my behavior?8 The researchers added, A healthcare worker with a high sense of self-efficacy toward infection prevention who also understands and believes in the organizations preventive goals will attempt to own, be committed to, and will strive to attain those goals.

The researchers recommend the following when planning a theoretically based intervention for improving infection control practices:

  1. Incorporate beliefs, perceived health threat, cues, self-efficacy, attitude, subjective norms, perceived behavioral control and intentions into any planned interventions.
  2. Consider factors in the work environment most likely to maximize effectiveness, including communication, participation, involvement of organization leaders, fairness, mutuality, respect and external/ internal re-enforcers
  3. Assess individual and group readiness before selecting any interventions
  4. Track and monitor processes in an ongoing evaluation of the interventions
  5. Avoid use of words such as compliance, replacing them with phrases that promote active participation and internalization, such as enhancing practice

Researchers have long known the factors that discourage hand hygiene. Noted hand-hygiene expert John Boyce, MD, says lack of awareness about situations that call for handwashing, personal and organizational attitudes toward handwashing, and various logistical barriers all contribute to non-compliance.9 Didier Pittet, MD and a team of researchers were the first to document that a high workload is associated with poor handwashing compliance.10

In their paper, Factors influencing handwashing behavior of patient care personnel, researchers Larson and Killien studied the habits of 193 healthcare personnel.11 These workers reported that the No. 1 reason for washing ones hands was the prevention of spread of infection among patients but the biggest factor against hand-hygiene compliance was cited as busy-ness. The study reported that individuals who washed infrequently (less than eight times per day) placed significantly more value on detrimental effects of frequent handwashing on their own skin and on the handwashing practices of their work colleagues than did individuals who washed frequently (more than 16 times per day). The study added, Frequent and infrequent washers did not differ significantly in their values regarding the factors favoring handwashing. Identifying factors that are determinants of whether one decides to wash ones hands or not are important in planning intervention strategies to improve practice. It appears that more emphasis should be placed on minimizing deterrents (especially detrimental effects on skin and peer pressure) rather than on emphasizing the importance of handwashing.

Enter the Machines

If removing deterrents is the answer to increased hand hygiene, the question is, what makes it easier for HCWs to comply? Industry, by way of technology, thinks it has a solution. One of the earliest ways to prevent cross contamination was to eliminate the necessity of touching sink faucets and paper towel dispensers. Enterprising companies engineered touchless systems without handles. Electronic components emit a continuous infrared beam that, when interrupted by a pair of hands placed under the faucet, will trigger a stream of water. Removing the hands turns the water off. In a similar vein, soap dispensers and paper towel dispensers housing similar sensors will discharge their contents without the user having to touch a level or a crank. Bringing touchless technology full circle, some systems offer full integration for streamlined handwashing without ever touching a surface.

A number of different systems is available. Best Sanitizers Inc. offers its safeHANDS Wash Station, designed for minimum splash and discharging water and pre-measured applications of soap and atomized sanitizer. World Dryers series of Automated Hand Wash Stations leads users through a complete hand sanitation process that includes soap, tempered water, and warm air or paper towel drying in a procedure that takes less than a minute. Infection Control Systems Inc.s Touchless Dispensing Systems With GermFighter is a line of automatic, touchless systems that dispense an instant hand sanitizer for killing germs without the use of water, paper towels or drying. In a similar vein, Kimberly-Clark Professionals no-touch dispensers fight cross contamination. The companys SANITOUCH NoTouch HACCP Roll Towel Dispenser allows users to grab a paper towel without touching cranks or levers, and the SANITOUCH Skin Care Dispenser uses an infrared sensor to automatically deliver the right amount of soap to the hands. Georgia-Pacifics enMotion series of automatic, touchless technology- driven paper towel dispensers promotes good hygiene by reducing the number of touch points in the restroom and lowers the risk of cross contamination when drying hands. Ecolabs Digitizer is a special gel soap dispenser that features an LCD counter to help monitor the number of handwashings for each employee group.

Putting an End to the Splash-and-Dash Technique

Since much of what constitutes handwashing these days is a quick (and frequently soapless) rinse under water, various systems incorporate a timing device that not only dispenses a cleansing agent, but tells the user when hands have been washed for a satisfactory amount of time to facilitate adequate scrubbing and rinsing.

Last fall, GoJo Industries introduced the iNXT TouchFree Dispensing System which features the Portion Rx advanced measurement technology, providing end-user control for dispensing based on efficacy requirements for portion management. In conjunction, the iNXT Signol device includes a hardware and software package that enables monitoring of hand-hygiene practices in applications in facilities where tracking and reporting are required. The device emits an audible signal to let users know when the 20-second handwash session is up, so there is no guesswork about the duration of the wash.

Giving HCWs a pass or fail system in the restroom is the Clean Hands Handwashing Monitoring System, which is equipped with an RF receiver attached to the wall of the entrance of the lavatory. The employee wears a badge that is detected as he enters the room, and the signal will be recorded into the central computer system. When the person is ready to wash his hands, he applies an amount of soap and rubs them vigorously together to form a reasonable amount of lather. He will place his hands under the Clean Hands Monitor, at which a real-time video of his hands will appear on the left of the screen. The monitor takes several seconds to allow time for the antibacterial agents to take effect. Then a colorized digital image is displayed on the right side of the screen showing the individual the areas with adequate soap, which appear as green, and the areas where more soap needs to be applied, which appear as red. The monitor will also display a pass or fail. If the person fails, he can rub his hands together more thoroughly and test again, or he can add more soap and repeat the process. Once a pass has been issued the person can return to work. The data is stored and is easily accessible by supervisors wishing to check the number of fails registered and actually view the stored image of the handwashing failures.

The HyGenius handwashing management system attaches to any existing handwashing sink or automatic wash system and is designed to verify individual handwashing compliance. The system administers a step-by-step, time- and termperature-controlled was automatically, without the user having to touch faucet handles. The water flows to allow proper and thorough wetting, then is automatically stopped while the built-in display instructs the user through the dispensing of soap, lathering, scrubbing, rinsing and drying. HyGenius also incorporates wash due reminders throughout the workday to ensure regular handwashing by each user. Any time a healthcare worker misses a handwash where minimum frequency requirements are in place, an audible tone will sound and a built-in indicator light will flash while the system displays the persons ID number for prompt notification.

In case these systems are a little too Big Brother for a facilitys tastes, the Amron Corporation has created a system called Hand Hygiene Prompts (HHP), a computer-based device that collects data from sensors which report room exit and entry, toilet use and hand hygiene compliance. From these data, HHP determines if a HCW should wash their hands, and plays a pre-recorded voice message over a loudspeaker to Please wash your hands if they do not. According to Amrons Stephen Lane, PhD, the system is non-intrusive, as users are not identified by badges or tags; it is non-threatening, because users are not penalized for not washing; it is non-coercive, because the device reminds, not commands; and it is neither stigmatizing nor invasive, as users are not identified as having dirty hands, and no cameras or microphones invade their privacy.

Amrons work in handwashing behavior modification through verbal messages has been funded by the National Institutes of Health for the past seven years, and successful clinical trials at Johns Hopkins University Hospital and Biloxi Specialty Hospital point to increased hand-hygiene compliance and decreased nosocomial infections.12

Initially, HCWs didnt like to hear the voice, but they realized it was reminding them to do something they know they are supposed to do, Lane says. They said, All right, Ill do it. That is what we are counting on. We are not coercing anyone to do it. They neglect to do it; they dont refuse to do it. So its a gentle yet effective reminder.

When people first hear the voice, they cant believe their ears, says Amrons Kevin Strauss. Then they say, Wow this really works. ICPs have told us it is exactly what they need. They always seem to be a warden for handwashing and with HHP, they dont have to be the bad guy anymore.

According to Lane, there have been no commercial sales of HHP yet, but hes hopeful hospitals will look past the $10,000 cost per 10-room ward and recognize they can save money in the long-term.

If HHP saves you two nosocomial infections per month, which is what our experimental study results indicated, it pays for itself immediately, Lane says. The difficulty is that hospitals dont seem to have a capital budget to buy something like HHP, related to not having a line item in their budget for nosocomial infections. But they pay for increased length of stay due to nosocomial infections.

Do the Machines Work?

Most clinicians say anything that facilitates proper handwashing is worth a try, and machines make it a no-brainer situation. Meritech, Inc. offers the CleanTech automatic handwashing systems designed to remove microorganisms from hands without contact. Users insert their hands into two open cylindrical chambers. As the hands enter, an optical sensor initiates the cycle; the cylinders begin rotating and hidden nozzles automatically spray a water and antibacterial solution combination. The system then rinses with non-irritating, high-pressure sprays of water. Hands are then dried with paper towels, air dryers or with a dryer incorporated into the system. The system is designed to ensure consistent water pressure, water temperature, soap usage, cycle length and skin coverage, and laboratory studies have shown a consistent bacteria reduction between 99 and 99.9 percent for the 12-second cycle.

In a 1990 study of the efficacy of handwashing machines, two Meritech systems were installed in a four-bed patient care area of an ICU.13 This was compared to another patient-care area that had a foot-operated antimicrobial agent dispensers as well as clean sinks for handwashing operated by foot pedals. All HCWs were observed to use the automated system 75 percent of the time, vs. 67 percent compliance in the manual hand-hygiene area. Also studied were only nurses using the automated area vs. the manual area for 40 days each. The study showed that the automated system decreased the total organism count compared to manual handwashing over the course of the nursing shift.

In a 1990 study, Larson and fellow researchers from Johns Hopkins University examined the effects of an automated sink on handwashing practices and attitudes of HCW in a postanesthesia recovery room and a NICU in two tertiary care hospitals.14 An automated sink was installed to replace a handwashing sink for about five weeks; the sink was then crossed-over for an equivalent time period to the other location. Handwashing practices of all HCWs were observed in three two-hour observation periods per week, amounting to 1,610 handwashes.

Handwashing practices differed significantly by site. For both sites, hands were washed significantly better but significantly less often with the automated sink (all p less than .001). HCWs expressed negative attitudes, however, about certain features of the sink, and these negative attitudes increased over the study period. The investigators concluded that Automated devices must be flexible enough to allow adjustments based on staff acceptance. Application of new technology to improve hand hygiene requires a multifaceted approach to behavior change.

The Handwashing Stations Role in Cross Contamination

As experts debate the role inanimate objects play in the transmission of infectious agents, few would doubt that the contamination of environmental surfaces such as handwashing sinks is a major issue.

Clearly inanimate surfaces play a role, particularly with organisms such as VRE and C. difficile, says Elaine Larson. But it seems pretty clear that direct contact (i.e., person-to-person touching) remains the most important mode of cross transmission. Nevertheless, housekeeping and environmental cleaning seem to have taken too much of a back seat and we need to re-emphasize the great importance of keeping the healthcare setting (as well as the people) free of a large microbial bioload.

Various studies have demonstrated infections stemming from faucet aerators15, splash from sink drains16 and handwashing machines17 In the paper, underwritten in part by Georgia-Pacific, Environmental surface cleanliness and the potential for contamination during handwashing, a team of researchers determined the organic, microbial and staphylococcal load on contact surfaces (faucet handles, soap dispensers and paper-towel dispensers) in four British hospitals that could be touched during handwashing, and to evaluate hand-mediated cross-infection.18 Manual faucet handles had a higher mean ATP level than manual soap or paper-towel dispensers, yet the latter were shown to present some presence of bacterial contamination. The study showed that contamination of hand-contact surfaces could act as a reservoir for microorganisms and could contribute to hand contamination before or after handwashing. In addition, the sink environment and its organic matter could serve as a breeding ground for potential pathogens.

The researchers concluded, Faucet handles have long been identified as a possible site for cross contamination between users, with the suggestion of either automatic faucets or the turning of faucet handles with used paper towels.19-20 Although overall, paper-towel dispenser exits carried the lower levels of contamination, the results are of prime concern as they are the final surface that may be touched during handwashing/ drying immediately preceding patient contact, and therefore may to some extent be more important.

How Clean is That Dispenser, Anyway?

A number of studies confirm that paper-towel dispensers are implicated in the transmission of infectious agents. In the paper, Bacterial transfer and cross-contamination potential associated with paper-towel dispensing,21 researchers from the United Kingdom and the United States studied the transfer and cross-contamination potential between hands, towels, and dispenser exits if one or more is contaminated using bacteria representative of the skins flora.

They wrote, Hand drying is the critical last stage of the handwashing process and needs to be implemented in a way that reduces, rather than increases, the risk of cross-contamination.22-23 This requires that the drying is effective and that contamination of hands does not take place.

However, concerns are now starting to be expressed about the dispensing of handwashing materials and the functionality of dispensing systems. 24-25 The three methods frequently used for hand drying are hot air dryers, cloth towels, and paper towels.26-28 Whereas paper towels are recognized as the most hygienic method of hand drying, paper towels, exits29 and dispensing mechanisms30-31 (levers and mount location), have been identified as potential sources of contamination, especially for paper towels hanging in sink splash zones.

The researchers used a generic wall-mounted paper-towel dispenser and a variety of different paper towels. Volunteers with either clean or contaminated hands were asked to remove, using a range of protocols, towels from dispensers which were either clean or contaminated. Previously clean surfaces were then microbiologically tested. The investigators found that recoverable bacterial transfer rates from a contaminated hand to clean dispenser exits ranged from 0.01 percent to 0.64 percent, depending on the bacteria used with an even higher transfer rate for clean towels. The reverse transfer, from contaminated exits to clean hands, was between 12.4 percent and 13.1 percent. The results indicate that zig-zag transfer of bacteria between paper-towel dispensers and hands can take place if either one is contaminated, and should be considered in the design, construction, and use of paper-towel dispensers.

The investigators wrote, This study has shown that even manual pull disposable folded towels and towel dispensers that are considered hands free or touchless can become contaminated if the surfaces at the dispenser exit are touched. This usually occurs when the paper towel is not cleanly delivered to a user, and this varies considerably depending on the compatibility of paper towel and dispenser combination.21 The total number of bacteria isolated from the dispenser exits after freeing a jammed towel with a contaminated hand was relatively low but should be viewed within the context of the number of times per day this activity may need to be carried out. It is also important to note that in some cases, although the minimum infective dose can be variable, only small numbers of pathogens, especially for intestinal disease, may be required to cause illness. A number of these pathogens are known to cause outbreaks in hospitals, therefore, even the low estimates obtained in the present study still allowed for sufficient bacteria to be transferred for them to exceed the minimum infective dose for a number of human pathogens. This was particularly true of the numbers transferred from wet, contaminated hands to dry towels remaining in the dispenser. The type of contamination demonstrated in this study, coupled with the survival potential of some pathogens causing hospital acquired infections, could also assist in the spread of organisms within the hospital environment.

They continued, There was an even greater transfer of both the resident and transient bacteria to the towels pulled or remaining within the dispenser. Paper towels with damp patches or spots may, in addition to being aesthetically unappealing, present an infection risk. Emphasis on decreasing accidental contact by educating and training healthcare and food workers may reduce the spread of pathogens and lower the risk of nosocomial infections. In addition, this work further highlights the need for careful selection of paper-towel types and their dispensers on the basis of functionality.

Handwashing Automation Can Save Time and Reduce Infection

By Jim OConnor

All doctors and nurses know the importance of washing their hands before and after contact with a patient, but do they always have the time to do it, and to do it properly?

Its a standard practice, but with busy schedules, complying is not always easy for some professionals, says Dr. Murray Favus, who was director of the Clinical Research Center at the University of Chicago for the last 19 years.

As an example, he describes the process of making patient rounds along with a small team of interns, residents and students.

Typically, as many as four of us might have patient contact, shifting a persons position in bed so we can examine his or her condition or change a dressing. A sink, soap and paper towels are in or near every room, but the cleaning process slows us down. If four people have to scrub down after seeing 15 patients in the morning, thats 60 handwashings.

Favus says everyone wants to follow policy, but no one wants to slow the teams progress. Not every washing is thorough.

Doctors and staff in the intensive care unit must be even more diligent, he says, pointing out that the sickest people require more frequent monitoring. They might be the most contagious, or have weak immune systems. A dozen or more doctors will examine or treat a patient in one day. Sometimes they need gloves, sometimes they dont. In any case, handwashing before and after can be critical.

Automation Could Save Time, Reduce Germs

To accelerate the handwashing process, some medical facilities have foot pedals to operate the faucets, or more sophisticated automatic faucets activated by sensors.

Not only is automation easier, but eliminating handles also eliminates potential cross contamination, he notes. Every time a doctor or nurse touches a handle, germs could be transferred to that handle.

Automatic faucets, also called touch-free faucets, are becoming increasing common in public restrooms, office buildings, schools, stadiums and other facilities with heavy traffic, and they make sense for healthcare facilities. Conversions to touch-free have been slow, however, because of the cost and the unreliability of some automatic faucets.

Thanks to advances in technology, those barriers are disappearing.

Earlier generations of automatic flushers and faucets were not always dependable, and some that are still on the market today have an unacceptable failure rate, says George Patrick Murphy, president and CEO of Technical Concepts, a manufacturer of touch-free restroom fixtures. Our companys goal was to develop dependable products that worked every time, and eventually paid for themselves through water conservation and little or no maintenance.

Last year, Technical Concepts introduced Radius Touch-Free Technology, an advanced operating system for flushers, faucets and related products. Our faucet sensors create a force field that surrounds the faucet, so the users hands dont have to search for the right spot, Murphy says. Water flows as soon as hands approach the faucet, and stop when the hands are removed.

Companies that supply restrooms with handtowel dispensers are doing their part to keep restrooms touch-free. The von Drehle Corporation offers a paper towel dispenser activated by a sensor, but says a faster and more popular product is its center-pull dispenser that has a paper towel sticking out of the bottom like a tail. When it is removed, the tail of another sheet appears. With either system, the user does not have to touch a button or turn a crank, says Steve von Drehle, president. Both dispensers provide one towel at a time, which is enough to dry your hands.

With the combination of these products, the handwashing process is not only faster, but nothing has to be touched except a fresh paper towel.

A Quick Return on Investment

Favus sees value in having automatic flushers in washrooms used by patients. Its one less step for a weak patient, he says. And if the patient needs a nurse or an aid to help him or her go to the bathroom, the assistant can concentrate on helping the patient return to bed without worrying about flushing. Again, there is no handle for anyone to touch or contaminate.

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