Problematic Hand Sanitation Can Lead to Healthcare-Acquired Infection

In the United States, healthcare-acquired infections (HAIs) afflict more than 3 million people every year. Approximately 8 percent of hospital patients acquire life-threatening infections during their stay. HAIs directly cause about 100,000 deaths annually and that number is growing rapidly due to new antibiotic-resistant strains of bacteria such as methicillin-resistant Staphylococcus aureus (MRSA). Treatment of HAIs extends patient stays an average of 21 days. The estimated direct cost to the 6,000 registered hospitals for HAI treatment is more than $5 billion, and the total estimated cost to society is as much as $30 billion.1 The infection problem is not limited to the U.S.; all developed nations suffer from similar HAI statistics. The total number of deaths worldwide rivals those from malaria. The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) officially characterize the enormity of the HAI problem as epidemic.2

The key underlying reason for such an enormous problem is the pathogen transmission cycle. This dynamic enables germs from the patient’s contaminated surroundings to be transported back and forth between all surfaces, including the patients themselves, and the healthcare workers (HCWs) who are treating them.3

The primary function of infection prevention solutions and practice is to break this transmission cycle, severing the pathways with speed and broad-spectrum efficacy. It is this inactivation4 or destruction of dangerous pathogens that prevents HAIs and related diseases. However, current infection prevention solutions are widely considered deficient or inadequate by a growing cadre of activists in the legal, insurance and consumer advocacy industries.5 The bottom line claim is that the transmission cycle still remains fully intact, and a lack of an effective and vigilant disruption of the cycle is a direct cause of the staggering and alarming aforementioned HAI statistics.

Problematic Hand Sanitation

As indicated in the Dancer paper,3 pathogens get on bare or gloved hands or clothing of the HCW from contact with a prior patient or from contact with contaminated surfaces, air and instruments. The compromised hands of the HCW then touch the patient while performing care-related tasks. The interaction between the hands of HCWs, whether they are bare or gloved, and their patient invariably transfers infectious pathogens to the patient.5 This is shown by Hayden,7 who documented gloved hand contamination from multiple tested sites within a patient’s room.

Bare-hand sanitation using alcohol-based sanitizing rubs is somewhat helpful when performed by a HCW between patient visits. However, it is done only 40 percent of the time or less.8 Often their use is avoided because busy schedules or the rubs cause significant hand irritation, or because of poor habit or discipline. Moreover, handwashing and alcohol rubs are not effective against all pathogens; in particular, alcohol rubs do not inactivate dangerous spores such as Clostridium difficile. Also, through carelessness, they generally do not cover the entire bare hand surface, with key spots missed frequently. As a result, they do not achieve sanitation, which is defined as inactivating 99.99 percent of all pathogens on the surface being sanitized. Poor bare-hand hygiene in hospitals is widespread.

The problem is much worse than just lack of bare-hand sanitation between patient visits. Even if there was 100 percent compliance, patients would still be a great risk. There is a tenuous relationship at best between increased bare-hand hygiene compliance and significant infection rate drops.9-10 This is because bare hands and gloved hands quickly lose their marginally sanitary condition during the patient visit. All touched surfaces compromise the conditions of the hands. All sanitation bets are off once the HCW enters and moves around the room, performing his or her tasks.

As a result, to lower the bioburden and counteract the contamination, it is necessary to repeat the sanitation process frequently during the patient visit or pathogens will be continuously transmitted to the patient and to the surroundings following the transmission cycle, and continually raising the risk of infection. The problem, of course, is that if it is so hard to achieve bare-hand sanitation between patient visits more than 40 percent of the time, it may not be feasible to rely on HCWs to perform multiple effective bare-hand sanitation during patient encounters due to limitations of speed, capability, and efficacy of existing technology.

Gloved Hands Can Be Lethal

HCWs wear exam gloves to protect themselves from infectious pathogens in the environment and from germs residing on the patient.11 Given the high levels of environmental contamination throughout hospitals, they are highly motivated to don gloves all the time. Glove use is on the rise due to increased fears by nurses of acquiring deadly infections. All glove manufacturers, first and foremost, promote the enhanced barrier protection capabilities of their products.12 However, wearing gloves does not necessarily protect the patient. As demonstrated earlier, it may do just the opposite — it may place them at further risk. Exam gloves can carry pathogens on their surfaces just as readily as skin stores transient pathogens on its surface. Gloved hands transfer pathogens to the patient as easily as compromised bare hands.13

Exam glove contamination from the patient room environment has been demonstrated in multiple technical papers.14 In one study, UVB light illuminates a pair of gloved hands revealing MRSA which has contaminated the exam gloves prior to initial patient care.15 These compromised gloves could potentially transmit harmful pathogens to the unsuspecting patient, who unfortunately becomes just another HAI statistic, and even back onto the HCW — posing risk to the next patient as well as themselves.

Conclusion

If things are left as they are, the HAI problem will get worse. The epidemic will spread deep and wide unless improper hand sanitation in hospitals is corrected. The recognized obstacles to hand sanitation must be overcome at the point of patient care to have a positive impact on healthcare outcomes. Since current approaches are not working, new convenient, broad-spectrum and user-friendly hand sanitation techniques must be developed and implemented.

A mandatory protocol, now increasingly recognized, would require instant gloved-hand sanitation each time the patient is about to be touched. The lack of such capability prevents a solution to the HAI problem no matter how assiduously bare-hand sanitation between patients is practiced. Forward-looking infection control experts all agree with this assertion.16

The winning strategy, making considerable strides toward the currently promoted zero tolerance goals,17 would be for HCWs to always don gloves and instantly sanitize them multiple times during patient encounters. Such an approach would dramatically lower infection rate due to significantly lowering the bio load on the gloved hands, by offering more convenience to the HCWs, and by adding another layer of protection for both nurses and their patients.

Cheryl Perkins is president of Innovationedge LLC, and a former senior vice president and chief innovation officer for Kimberly-Clark Corporation.

References:

1. http://www.hospitalinfection.org/

2. www.cdc.gov/ncidod/dhqp

3. Dancer SJ. The Lancet Infectious Diseases. Vol. 8, No. 2. Pp. 101-113. February 2008.

4. Inactivation means the pathogen has been rendered no longer able to reproduce, which effectively ends the potential for infection.

5. Class-action lawsuit seeks $50M over C. difficile deaths. CTV, July 10, 2008.

6. Kampf G and Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clin Micro Rev. Vol. 17, No. 4. Pp. 863-893. October 2004.

7. Hayden M. The risk of hand and glove contamination after contact with a VRE positive patient environment. ICAAC, 2001.

8. http://www.hospitalinfection.org

9. Hospital study shows improvement in hand hygiene compliance but no reduction in infection rates. Healthcare Purchasing News. March 2008.

10. Backamn C, Zoutman DE and Marck PB, An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of healthcare-associated infections. Am J Infect Cont. Vol. 36, No. 5, Pp. 333-348.

11. OSHA standards 1910 (1030)(3)(ix)

12. http://www.ansellhealthcare.com

13. Truscott W. The role of PPE in contact transfer. Infection Control Today. October 2005.

14. Jonel Aleccia citing Dr. Curtis Donskey. Clinical Infectious Diseases, February 2008; also: Watch what you touch: A bad germ get worse: C. diff rivals MRSA as the next deadly bacteria. MSNBC, May 2, 2008.

15. MRSA shows up as a phosphorescent greenish glow under a blacklight at the VA Hospital in Pittsburgh. Photo by Jeff Swensen/NYT.

16. Snyder GM, Thom KA, Furuno JP, Perencevich EN, Roghmann MC, Strauss SM, Netzer G, and Harris AD. Detection of methicillin-resistant Staphyloccous aureus and vancomycin-resistant Enterococci on the gowns and gloves of healthcare workers. Infect Cont Hosp Epidem. June 12, 2008.

17. Pyrek K. Zero tolerance for infections: A winning strategy. Infection Control Today. January 2008.

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