Handwashing: Problems and Solutions: Part II
by David L. Dyer, PhD
Several studies have indicated that the issue of handwashing non-compliance by physicians is complex. Larson43 points out that operator compliance with product use is not only dependent on its clinical performance but also on its subjective acceptability (packaging, odor, etc.) and on the individual perception of product harshness with prolonged use. In a review of the barriers to handwashing compliance, Springthorpe and Sattar44 identified three main obstacles: 1) the amount of time needed for proper handwashing; 2) the convenience and user-acceptability of handwashing and hand-drying facilities, and 3) the condition of the skin barrier. It is clear that handwashing compliance may suffer in understaffed clinical settings. Staff increases require increased spending, which in the present era of cost reductions by health maintenance organizations may not be achieved easily. The great cost of nosocomial infections to healthcare systems may outweigh any financial benefits recovered through increasing patient/staff ratios and jeopardizing compliance with basic universal precautions.44 Voss and Widmer23 indicate that the time needed to achieve 100% compliance with present handwashing guidelines could decrease the time available for other routine cleaning and disinfection and adversely impact overall patient care. The authors further indicated that the use of appropriate instant hand sanitizers might be a time-effective alternative to handwashing. Such an improvement might increase the convenience and accessibility of hand sanitization for physicians. In that study, the 16 hours required for maximal compliance with soap and water practices shifted to only three hours when bedside dispensers for instant sanitizers were made available. Care should be taken to ensure that bedside dispensers are not contaminated with frequent use. A touch-free design for a dispenser in such a frequent-use setting is, therefore, desirable; however, design flaws associated with present touch-free systems (based on infrared light detection alone) can cause inappropriate product release, which can result in increased maintenance costs and even in injury to the public in the event that the product is released onto the floor.45-47 Such flaws have been a limiting factor to the widespread use of touch-free systems in the US. An improved dispenser, which releases product based on the detection of both human bioelectric field and infrared light greatly decreases the chance of misdispensing the product. Cost-effective dispensers that incorporate this type of detection system are anticipated to be available to the medical community by Fall 2000.48 Care should be taken to determine the potential for their long-term acceptance and utility in different healthcare settings. Automated devices should be flexible enough in implementation and use to allow adjustments based on staff acceptance.49
A significant impediment to proper handwashing is the condition of the hands, in particular whether the product causes painful chapping or dermatitis with frequent use. Smit, et al.,50 indicated that nursing staff have a prevalence of hand dermatitis and chapping of about 30%. Larson51 reported that although skin damage was apparent in 25% of observed nurses, 86% rated themselves as having some sort of skin problem. Such difficulties associated with handwashing and gloving practices can affect compliance and, therefore, increase pathogen carriage on the hands. Because of this effect, the infection control staff should ensure that any formulation accepted for frequent use is non-irritating and has a minimal potential for skin sensitization. It is important to realize that skin reactive properties of active ingredients are, just as for antimicrobial activity, highly formulation dependent. For example, sodium lauryl sulfate is known to disrupt the stratum corneum water barrier and can cause hand dermatitis associated with handwashing.52-53 This adverse effect is amplified with the use of gloves and in high temperature situations54-55 but can be avoided if urea is added to the formulation.56 Another example is benzalkonium chloride, which has been approved for use in a topical antiseptic application at 0.13% v/v57 but which can be a dermal irritant at this and higher concentrations.58-59 In the context of a formulation containing amphoteric and nonionic surfactants and allantoin, however, antimicrobial effectiveness is improved with the minimization of dermal irritancy and sensitization.60
Is Staff Education an Effective Solution?
Efforts have also been made to improve handwashing compliance through physician and staff education programs. In one study, Dorsey, et al.,61 found that minimal intervention via posting of CDC handwashing recommendations and the distribution of educational material resulted in a noticeable but statistically insignificant improvement in total handwashing. Interestingly, this study also indicated that nurse practitioners and registered nurses had significantly higher adherence to recommended handwashing between patients than emergency physicians did. Mayers, et al.,62 observed a nursing staff for three months, and then substituted the normal hand sanitizer with an emollient based formulation in parallel with implementation of a daily program of feedback to nurses on their handwashing frequency. While no increase in handwashing was observed upon switching to the emollient-based sanitizer, feedback provided to the experimental ICU increased handwashing frequency to 92% of the required levels and was significantly higher than handwashing in the control unit. A follow up observation, however, indicated that when feedback was removed, compliance fell to baseline levels. Similar findings regarding the effectiveness of education feedback and enforcement have been presented by Conly, et. al.,63 and Dubbert, et. al.64 In the latter study, education alone produced an immediate improvement in compliance, which declined to baseline four weeks after instruction ended. Because the obstacles to handwashing compliance are interrelated, they may be very difficult to resolve.43 Specifically, changing only one parameter may not change hand-cleansing behavior in the long term. Ironically, even multifaceted intervention attempts have failed to achieve long-term success. In a prospective study, Larson, et. al.49 implemented intervention, which included focus group sessions, installation of automatic sinks, and feedback to staff on handwashing frequency. Although some significant differences between the control and experimental ICU units were observed during active intervention, the differences had returned to baseline by the two-month follow-up.
Overall, it seems that a common method in studies that have demonstrated a measure of even temporary success at improving handwashing compliance is that of consistent monitoring of performance followed by feedback. Maintenance of a feedback program is difficult to achieve due to costs and time constraints of healthcare personnel. Increasing the community's awareness of the importance of handwashing could have a favorable impact on the compliance rate of handwashing in healthcare workers.66 McGuckin, et. al.,67 performed a six-week intervention/control study at four community hospitals consisting of two general medical/surgery in-patient floors with no obstetric of pediatric patients and with each hospital serving as its own control. Within 24 hours of admission, patients were educated on the importance of asking their healthcare workers to wash their hands prior to touching them. The follow-up indicated that 81% of the patients enrolled in the study read the educational pamphlet on handwashing that was provided, and 57% asked their healthcare workers whether they had washed their hands. Fifty-seven percent of the healthcare personnel that were asked responded favorably to the inquiries. This patient handwashing education model was found to improve healthcare handwashing compliance by approximately 34% as measured by increased soap usage. The cost savings estimated with the implementation of the patient-education model in a 300 bed 10,000 admission hospital range from $50,000-$60,000 per year, based on approximately 160 preventable infections per year. Overall, it appears that this latest method of patient-based intervention meets the need for a sustainable program of reinforcement of good handwashing practices in healthcare workers.
David L. Dyer, PhD, is the Research Director, at Woodward Laboratories, Inc. (Los Alamitos, Calif).
Note: Part I of this article can be found in the April issue of Infection Control Today®.