Growth in Hospital-Acquired Infections

November 1, 2000

Automatic Handwashing Systems

By Christopher Drummond

Modern healthcare has long struggled with problems related to handwashing.The FDA says that 80 million cases of food poisoning occur in the United Stateseach year and associated costs are estimated to be between $7.6 and $23 billionannually. Additionally, over 70% of all outbreaks originate in food serviceoperations and as many as 40% are the result of poor handwashing.

Growth in Hospital-Acquired Infections

According to the CDC, the hospital- acquired infection rate is increasing.The CDC estimates these infections contribute to at least 80,000 patient deathseach year, and approximately 5 to 10 % of patients annually contract infectionswhile in the hospital. Nosocomial infections kill more Americans every year thantraffic accidents.

According to a recent article in AJIC, handwashing is the single mostimportant procedure in the prevention of nosocomial infections. According to theCDC, half of the infections that are acquired in hospitals could be prevented byeffective handwashing. A 1994 study published in AJIC studying glove use andhandwashing practices in a hospital concluded that although policies andprecautions have been implemented to enforce proper handwashing practices, staffmembers washed hands after only 32% of high-level (exposure to body fluids)contacts, and that proper handwashing only occurred 12% of the time. Inaddition, the level of compliance varied significantly among different units inthe same hospital. This suggests that handwashing and glove use are notpracticed with blood and body fluid contact despite education in precautions andwritten infection control policies.

Compliance with handwashing has historically been poor. When surveyed,hospital staff members overestimate the frequency with which they wash theirhands, as well as the duration of handwashing. Increasingly hectic schedules,the inconvenient placement of sinks, and lack of education about properhandwashing account for lack of compliance. To encourage increased compliance,more innovative feedback and educational endeavors are needed as well as ways tomake the handwashing process easier and faster.

Data collected over five years from an intensive care unit showed that thehospital-acquired infection rate decreased almost 60% when an education andenforcement program for handwashing was implemented. The rate of infection thenslowly increased over the next four years, until another program was instituted,when it was again gradually reduced. The rise in infection rate was attributeddirectly to handwashing practices, and indirectly to personnel turnover (AJIC).Many healthcare professionals wash only the palms and backs of their hands,whereas the main contact points are the fingers and fingertips. Where no controlfor agent, duration, or technique exist, the institution of standardizedhandwashing technique alone results in a decrease in infection rates (AJIC).

Use of Automatic Handwashers

In 1983, an OB/GYN physician and an owner of car-washing facilities createdautomatic handwashing systems for use in healthcare. Consequently, they createda company called Meritech, Inc. to facilitate this idea. By 1989, after sixyears of effort, the company developed the first prototype of an automatichandwashing system. Approximately 18 hospitals adopted this technologyimmediately. However, the systems were large, expensive ($11,000), andunreliable. In the early 1990s the technology improved and became known asCleanTech automatic hand and glove washing systems. In the mid-1990s Meritechdeveloped the CleanTech 2000S system--smaller, more cost effective, and morereliable. Then in 1999, Meritech introduced the CleanTech 400. The CleanTech 400serves as a sink in addition to handwasher. In the early 1990s, many marketsincluding healthcare, food processing, produce, supermarkets, food service,cleanrooms, and daycare facilities began using the benefits of these systems.

CleanTech automatic handwashing systems are designed to removemicroorganisms, bacteria, pathogens, and particles from hands and gloves withouthand-to-hand contact. Users simply insert their hands into two open cylindricalchambers. As the hands enter, an optical sensor initiates the cycle; thecylinders begin rotating and hidden nozzles (20 in each cylinder) automaticallyspray a water and antibacterial solution combination on the hands and under thefingernails. The automated handwasher then rinses with non-irritating,high-pressure sprays of water. Hands or gloves are then dried with paper towels,air-dryers, or with a dryer incorporated into the system.

This automatic handwashing system performs the wash and increases handwashingcompliance up to five times that of manual handwashing methods.

Applications

Automatic handwashing has gained popularity in many industries: hospitals,doctor's offices, dental offices, clinics, retirement facilities, assistedliving facilities, daycare facilities, pharmaceutical clean rooms, dairy, beef,poultry, and more. There are many common and specific reasons for each type ofindustry to use automatic handwashers.

Image is the most common reason for the popularity of automatic handwashing.Many automatic handwashing customers invested in the advanced technology becauseit was popular with their customers. Whether the customers are patients,consumers or business customers, owning state of the art handwashing technologydemonstrates that a company is committed to safety.

Especially in healthcare, handwashing compliance is important. Automatichandwashing significantly increases employee handwashing. Employees use theautomatic handwasher because it is gentler on the hands. No training isrequired--employees simply put their hands in the handwasher. Because anautomatic handwasher controls the water, temperature, soap dispensing, the on-and off-function, and the system cleaning, it is convenient to use.

The Science and Efficacy of Automated Handwashing

The concept behind automatic handwashing is to remove the significantvariability in effectiveness of a manual handwash. The technique used to washhands manually varies from one person to the next. Further, there is variabilityin how well the person cleans under the fingernails, between the fingers, on thebacks of the hands and around the wrists. Manual handwashing can be as effectiveas automatic handwashing if the wash process is done correctly; however, it ismuch less effective when done poorly. By automating the wash process thisvariability is minimized. The design of the CleanTech system ensures consistentwater pressure, water temperature, soap usage, cycle length and skin coverage.This allows consistent bacteria reduction from one pair of hands to the next.The activity of the wash cycle via an infrared sensor allows no-touch operationand prevents cross contamination. The system also washes each hand individually,eliminating the hand-to-hand contact used in a manual handwash. Laboratorystudies have shown a consistent bacteria reduction of between 99 and 99.9%.

In some field applications of the automatic handwashing system, the system isused to remove bacteria from a gloved hand rather than a bare hand. Testing hasshown that these systems effectively remove organisms from gloves as well ashands. One of the driving forces behind the creation of automated handwashingwas the variability of manual handwashing. To quantify this variability, testingwas conducted to define a typical manual handwash and measure the standarddeviation from one wash to the next. This data was then compared to the resultsfrom an automated handwash. This study showed that automated handwashes aresignificantly more consistent in bacteria reduction than manual handwashing.

Compliance

Many automatic handwashing users report that employees are three to fourtimes more likely to wash their hands when an automatic handwasher is used. Somecustomers went so far as to conduct studies on employee handwashing compliancerates with automatic handwashing versus manual handwashing. People tend to usethe automatic system much more than a manual handwash sink because they enjoythe sensation of washing in the automatic system.

Compliance is defined as the ratio of the number of times a handwash isperformed over the number of times handwashing is required by protocol.Compliance rates of 100% are very rare and usually only occur when the washprocess is either monitored by a supervisor or when employees not complying withthe handwashing protocols are refused entry into the facility. This monitoringintensive system is usually implemented only in critical manufacturing processessuch as semiconductor cleanrooms, where the cost of product contamination canrun into the millions of dollars from a single incident. Most other facilitieshave a less than perfect compliance rate (30 to 60% is typical).

The automatic handwashing system has a compliance monitoring system thatcounts the number of hand washes occurring in the machine. This allows thesupervisor to measure whether employees are washing their hands as frequently asrequired. With this option, the supervisor has the ability to reset the counterperiodically, e.g., every shift. This provides information on employeehandwashing on a real-time basis. An individual compliance-monitoring system isalso available with this system. In one automatic handwashing system, eachemployee enters his or her number on an attached keypad. The supervisor can thenprint a report describing each employee's frequency, duration and time ofhandwashing every shift.

CleanTech washers have been tested by Underwriters Laboratory for compliancewith UL544 criteria and have been determined to meet these requirements and areUL listed. This listing means that the mechanical and electrical systems in theunit have been tested safely. The National Sanitation Foundation (NSF) hasexamined the same units and has given NSF approval under category C2. Thisapproval means that the units are constructed in a manner that is sanitary,easily cleaned and safe to operate around food.

For many years, the USDA was also in charge of approving the chemicals usedin the system. The chemicals were tested for minimum performance and thencategorized into various applications such as hard surface disinfecting,handwashing, or hand sanitizing. With the implementation of the HACCP program bythe USDA, the role of the agency has changed dramatically in respect to therelationship with the manufacturer. Rather than the old method of having aninspector walk the plant and look for conditions which violated USDAregulations, the manufacturer now defines their own regulations and standardsanitation operating procedures which are approved by the USDA. The HACCPprogram then requires the company to police themselves by monitoring the definedcritical control points to ensure compliance and record the data for review bythe inspector in charge. Consequently, the USDA does not approve eitherequipment or chemicals for use in inspected plants; rather, the user isresponsible for specifying the equipment or chemicals which meet their ownrequirements, as outlined in the HACCP program. Because of the compliancemonitoring systems, automatic handwashers are complimentary to any HACCPprogram.

The Technology

Automatic handwashing systems are available in several different models. Somehave a plastic housing and others are constructed of all stainless steel. All ofthe CleanTech units have the same basic components and operate similarly.

The unit is activated when the infrared photoeye beam (invisible to the humaneye) is broken by the placement of the hands into the two round cylinders. Theunit then begins a preprogrammed cycle consisting of a period of time in thebeginning of the cycle during which antimicrobial solution is mixed with waterand dispensed onto the hands. Next, only water is dispensed onto the hands torinse the soap off. Typically, the total cycle length is about 12 seconds, threeof which is the soap and the water mixture.

The rotating cylinder assembly consists of an inner and outer cylinder madefrom ABS plastic. The inner cylinder is slightly smaller in diameter than theouter which allows the two parts to nest together. Water enters the cylinderassembly through the inlet located at the closed end of the outer cylinder. Thewater fills the space between the inner and outer cylinder until it reaches theo-ring seal between the two at the open end. At this point the only place forthe water to go is out through the series of 20 nozzles installed throughout thewall of the inner cylinder. These nozzles are arranged in a helical pattern sothat as the assembly rotates clockwise, the helical pattern will wash debrisfrom the wrist area down off the end of the fingertips. There are also fournozzles located in the bottom of the inner cylinder that direct water sprayunder the fingernails, an area which is often missed in manual washing.

Water temperature, motor speed, soap draw and cycle length are all adjustablethrough a potentiometer on the printed circuit board within the electronicsmodule.

In one version, the hand drying option will dispense heated, compressed aironto the hands after the completion of the wash cycle. The operator moves theirhands in the air stream that dries the hands through a combination of mechanicalair removal and evaporation. The dry cycle takes between 40 and 60 seconds.

Chemical Washing Solutions

A variety of solutions have been tested for efficacy and compatibility withthe automatic handwash systems. These include: Chlorohexidine Gluconate in 4%concentration (CHG 4%), Chlorohexidine Gluconate in 2% concentration (CHG E-2),Quat E-2, Quat E-3 and A-1 Self-Clean. The first three chemicals listed are usedfor handwashing, the Quat E-3 is used for hand sanitizing and the A-1 Self-Cleanis used for hard surface disinfecting.

The plumbing tree in CleanTech systems is incompatible with chlorine-basedsolutions. The highest volume soap used, the CHG E-2, has been found to be mosteffective in reducing transient and resident bacteria.

Alcohol-based waterless gels that are simply rubbed into the hands andallowed to evaporate are not a substitute for handwashing. Several differentvarieties of no-touch handwashing units are available which range from simpleno-touch faucet-activated sinks to systems that will dispense water, soap, andwarm air for drying, all using a no-touch design. These systems represent animprovement over the traditional hand-activated units because they can preventcross contamination from one user to the next. They do, however, require amanual handwash; therefore, the variability from one wash to the next is stillan issue. Gloves--thought by some to be the ultimate protection for consumersfrom food-born illness--have some significant problems according to recentstudies. The rate of bacterial growth under a glove may be higher than on a barehand. This would not be a problem if the gloves were an impenetrable barrierbetween hand and the product being touched by the gloved hand, but this is notthe case. Gloves may have defects, allowing the transmission of bacteria fromthe hand to the product. In many cases, the glove provides a false sense ofsecurity so that employees are less likely to wash their hands.

Conclusion

Automatic handwashing offers standardized procedure, increased compliance,and increased efficacy over typical manual handwashing. Because of thesebenefits and the fact that it pays for itself in a short time, automatichandwashing is fast becoming the standard in many healthcare applications.

Christopher Drummond is the President and CEO of Meritech, Inc. The designengineer responsible for designing the hanwasher is Christopher Maybach.Meritech was formed more than 10 years ago and focuses on automatic handwashers.