Handwashing Stations Harboring Bacteria Can Undo Hand-Hygiene Efforts
By Kelly M. PyrekHealthcare workers who are well versed in proper handwashing procedures may not be aware of the subtle undoing of their hand-hygiene diligence by the very facilities they use to degerm their digits. This concept was explored by Christopher J. Griffith, PhD, and a team of researchers from the University of Wales, PHLS Laboratory and Georgia-Pacific Corporation in a study of environmental surface cleanliness and the potential for contamination of hands during the handwashing process.1 The authors say that proper hand hygiene consists of five components: hygienic state of hands; hand hygiene compliance; effective handwashing; hand drying; and a critical step, the prevention of hand contamination at any time during the entire handwashing process. As the authors emphasize, "Terminal or end-process contamination may negate the value of all the previous components." The Griffith et al study was conducted in four hospitals in the United Kingdom and the sampling was conducted unannounced so as not to incur changes in the routine cleaning process. In describing the average handwashing station, the study reported that 60 percent of sinks had faucet handles consisting of lever arms; all paper-towel dispensers were manual pull of folded towels and devoid of handles and buttons; and all soap dispensers required a surface to be touched in order for the product to be dispensed. Healthcare workers were observed to use the faucet handles incorrectly, ignoring no-touch hand contact instructions clearly posted, as well as touching the soap dispensers with wet hands. Sampling was conducted with aerobic colony counts (ACC) and adenosine triphosphate (ATP) assays that measure the level of organic debris, skin cells and microorganisms remaining on a surface. The study reported that faucet handles had a higher ATP level than soap or paper towel dispensers as well as higher ACCs and staphylococcal colony counts. The study also showed that paper-towel dispensers, which carried the lowest ATPs and ACCs, present a cross contamination risk if touched. Five percent of the faucet handles had some visible surface wetness, whereas all paper towel and soap dispensers were visually dry. The researchers concluded, "The pattern that emerges is one with faucet handles presenting the greatest risk, being most contaminated and more likely to be wet and exceed benchmark cleaning values. Because these surfaces may be touched early in the handwashing process, the high failure rates with ATP could be a result of contamination from hands carrying high quantities of organic matter before washing ... Although overall paper towel dispenser exits carried the lower levels of contamination, the results are of prime concern as they are the final surface to be touched during handwashing/drying immediately preceding patient contact, and, therefore, may to some extent be more important." The researchers emphasize that a large number of organisms present on the surfaces of handwashing and hand drying stations were staphylococci, with the possibility of including methicillin-resistant Staphylococcus aureus, and that surfaces with the potential for recontamination should be included in cleaning programs to minimize cross- infection. The researchers reported that studies involving the cleaning of more than 2,500 surfaces (including those found in healthcare settings) of varying conditions using a standardized cleaning program, indicate that if a surface is not damaged, counts of less than 2.5 colony-forming units are attainable and used as benchmark values. The researchers add that no standards have been established by infection control practitioners (ICPs) for hospital surfaces in terms of microbial counts. The researchers stated, "It has been argued that meaningful microbial standards relating to air and surface contamination are lacking and routine environmental culturing is useful to identify epidemic sources. However, use of hygiene surface monitoring to evaluate routine hospital cleaning and to establish cleanliness standards is both cost-effective and instructive, as it provides real-time information on surface contamination, especially in relation to the cost of cleaning, and would be another tool to help reduce hazards in critical-care environments." Researchers acknowledge the popularity of no-touch hand-hygiene systems such as hot-air dryers and automatic sinks, and point to various studies about their efficacy. Wurtz2 and a team of researchers from the University of Illinois School of Public Health say that although handwashing is considered an important factor in the prevention of nosocomial infections, the optimal technique has not been determined and compliance is often difficult to obtain. They acknowledged that handwashing compliance is particularly important in intensive-care areas and reported that Cook County Hospital purchased three handwashing machines for its surgical ICU department. Wurtz et al reported that handwashing compliance was poor but improved from 22 percent to 38 percent when the handwashing machines were in use; nurses preferred handwashing at the sink and physicians preferred the handwashing machine. Technology may sometimes add to cleanliness woes, as a group of researchers from Altru Health System in North Dakota discovered.3 They found that certain brands of electronic water faucets used in the hospital were associated with unacceptable levels of microbial growth in water and was a continuing source of bacteria potentially hazardous to patients. Of 169 faucets tested, 13 (22 percent) of 59 electronic faucets exceeded the heterotrophic plate counts (HPC) threshold, and 12 (11 percent) of 110 manual faucets exceeded the HPC threshold (P<.14). A comparison of two brands of electronic faucets with manual faucets and with each other revealed that the HPC threshold was exceeded by 11 (32 percent) of 34 brand A faucets as compared to 12 (11 percent) of 110 manual faucets (P<.006). The HPC threshold was exceeded by two (8 percent) of 25 brand B faucets compared to 12 (11 percent) of 110 manual faucets (P<.94). Contamination rates of brand A and brand B faucets differed significantly (P<.003). As mundane a topic as it may be, researchers at the University of Wales conducted a study to determine contamination exposure routes of folded paper towel dispensing.4 The researchers wrote, "Paper towels are generally accepted as the most hygienic means of drying hands and are often distributed from generic dispensers. Effective dispensing of towels is of importance economically and may influence infection control objectives if hands become contaminated during hand drying." The study identified potential exposure routes for hand contamination and evaluated the efficiency of paper-towel dispensing as applied to five different folded paper towels using a generic wall-mounted dispenser. Eighteen male and female participants of varying heights participated in pull testing of 400 paper towels each, in controlled hand-drying simulations. All events having the potential for hand contamination, including towel jamming, towels falling onto the floor, and incidental contact of paper exits, were monitored and documented. There was considerable variation in dispensing efficiency between different towel brands. One towel (Z) had significantly (P <.05) superior dispensing properties from the generic dispenser. Participants of a shorter height obtained a lower incidence of dispensing malfunctions using all towel products and type. The results indicated likely contamination exposure routes and wastage levels for each towel type. In conclusion, the researchers wrote, "Environmental services managers and infection control practitioners should carefully consider, for economic and infection control reasons, the siting and design of towel dispensers and the types of towel purchased."