Handwashing Stations Harboring Bacteria Can Undo Hand-HygieneEfforts

June 1, 2003

Handwashing Stations Harboring Bacteria Can Undo Hand-HygieneEfforts

By Kelly M. Pyrek

Healthcare workers who are well versed in proper handwashing procedures maynot be aware of the subtle undoing of their hand-hygiene diligence by the veryfacilities they use to degerm their digits. This concept was explored byChristopher J. Griffith, PhD, and a team of researchers from the University ofWales, PHLS Laboratory and Georgia-Pacific Corporation in a study ofenvironmental surface cleanliness and the potential for contamination of handsduring the handwashing process.

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The authors say that proper hand hygiene consists of five components:hygienic state of hands; hand hygiene compliance; effective handwashing; handdrying; and a critical step, the prevention of hand contamination at any timeduring the entire handwashing process. As the authors emphasize, "Terminalor end-process contamination may negate the value of all the previouscomponents."

The Griffith et al study was conducted in four hospitals in the UnitedKingdom and the sampling was conducted unannounced so as not to incur changes inthe routine cleaning process. In describing the average handwashing station, thestudy reported that 60 percent of sinks had faucet handles consisting of leverarms; all paper-towel dispensers were manual pull of folded towels and devoid ofhandles and buttons; and all soap dispensers required a surface to be touched inorder for the product to be dispensed. Healthcare workers were observed to usethe faucet handles incorrectly, ignoring no-touch hand contact instructionsclearly posted, as well as touching the soap dispensers with wet hands.

Sampling was conducted with aerobic colony counts (ACC) and adenosinetriphosphate (ATP) assays that measure the level of organic debris, skin cellsand microorganisms remaining on a surface. The study reported that faucethandles had a higher ATP level than soap or paper towel dispensers as well ashigher ACCs and staphylococcal colony counts. The study also showed thatpaper-towel dispensers, which carried the lowest ATPs and ACCs, present a crosscontamination risk if touched. Five percent of the faucet handles had somevisible surface wetness, whereas all paper towel and soap dispensers werevisually dry.

The researchers concluded, "The pattern that emerges is one with faucethandles presenting the greatest risk, being most contaminated and more likely tobe wet and exceed benchmark cleaning values. Because these surfaces may betouched early in the handwashing process, the high failure rates with ATP couldbe a result of contamination from hands carrying high quantities of organicmatter before washing ... Although overall paper towel dispenser exits carriedthe lower levels of contamination, the results are of prime concern as they arethe final surface to be touched during handwashing/drying immediately precedingpatient contact, and, therefore, may to some extent be more important."

The researchers emphasize that a large number of organisms present on thesurfaces of handwashing and hand drying stations were staphylococci, with thepossibility of including methicillin-resistant Staphylococcus aureus, and thatsurfaces with the potential for recontamination should be included in cleaningprograms to minimize cross- infection.

The researchers reported that studies involving the cleaning of more than2,500 surfaces (including those found in healthcare settings) of varyingconditions using a standardized cleaning program, indicate that if a surface isnot damaged, counts of less than 2.5 colony-forming units are attainable andused as benchmark values. The researchers add that no standards have beenestablished by infection control practitioners (ICPs) for hospital surfaces interms of microbial counts.

The researchers stated, "It has been argued that meaningful microbialstandards relating to air and surface contamination are lacking and routineenvironmental culturing is useful to identify epidemic sources. However, use ofhygiene surface monitoring to evaluate routine hospital cleaning and toestablish cleanliness standards is both cost-effective and instructive, as itprovides real-time information on surface contamination, especially in relationto the cost of cleaning, and would be another tool to help reduce hazards incritical-care environments."

Researchers acknowledge the popularity of no-touch hand-hygiene systems suchas hot-air dryers and automatic sinks, and point to various studies about theirefficacy.

Wurtz

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and a team of researchers from the University of IllinoisSchool of Public Health say that although handwashing is considered an importantfactor in the prevention of nosocomial infections, the optimal technique has notbeen determined and compliance is often difficult to obtain.

They acknowledged that handwashing compliance is particularly important inintensive-care areas and reported that Cook County Hospital purchased threehandwashing machines for its surgical ICU department. Wurtz et al reported thathandwashing compliance was poor but improved from 22 percent to 38 percent whenthe handwashing machines were in use; nurses preferred handwashing at the sinkand physicians preferred the handwashing machine.

Technology may sometimes add to cleanliness woes, as a group of researchersfrom Altru Health System in North Dakota discovered.

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They found thatcertain brands of electronic water faucets used in the hospital were associatedwith unacceptable levels of microbial growth in water and was a continuingsource 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 faucetsand with each other revealed that the HPC threshold was exceeded by 11 (32percent) of 34 brand A faucets as compared to 12 (11 percent) of 110 manualfaucets (P<.006). The HPC threshold was exceeded by two (8 percent) of 25brand 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 Walesconducted a study to determine contamination exposure routes of folded papertowel dispensing.

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The researchers wrote, "Paper towels aregenerally accepted as the most hygienic means of drying hands and are oftendistributed from generic dispensers. Effective dispensing of towels is ofimportance economically and may influence infection control objectives if handsbecome contaminated during hand drying."

The study identified potential exposure routes for hand contamination andevaluated the efficiency of paper-towel dispensing as applied to five differentfolded paper towels using a generic wall-mounted dispenser. Eighteen male andfemale participants of varying heights participated in pull testing of 400 papertowels each, in controlled hand-drying simulations. All events having thepotential for hand contamination, including towel jamming, towels falling ontothe floor, and incidental contact of paper exits, were monitored and documented.There was considerable variation in dispensing efficiency between differenttowel brands. One towel (Z) had significantly (P <.05) superior dispensingproperties from the generic dispenser. Participants of a shorter height obtaineda lower incidence of dispensing malfunctions using all towel products and type.The results indicated likely contamination exposure routes and wastage levelsfor each towel type.

In conclusion, the researchers wrote, "Environmental services managersand infection control practitioners should carefully consider, for economic andinfection control reasons, the siting and design of towel dispensers and thetypes of towel purchased."