Infection Control Today - 03/2004: Handwashing and Cross Contamination

March 1, 2004

Handwashing and Cross Contamination: Old Issue, New Approaches

Handwashing and Cross Contamination:
Old Issue, New Approaches

By Kelly M. Pyrek

With numerous hand-hygiene studiesin the literature, theres plenty of data confirming what we already know actual handwashing compliance (and not just self-reported incidences) is 30 to50 percent.1 Also well documented is the role handwashing plays in crosscontamination a source of hospital acquired infections.

Some experts recognize that efforts to increase handwashingepisodes must be focused on changing actual healthcare worker (HCW) behavior,not simply improving their knowledge of handwashing requirements.

With the new alcohol products, hand hygiene will be more ofa behavioral issue and less of a time or convenience issue than it has been inthe past, says Elaine Larson, RN, PhD, FAAN, CIC, associate dean andprofessor of pharmaceutical and therapeutic nursing at Columbia University.

Researchers are paying more attention to the link betweenhabit formation and behaviors such as handwashing. Studies of human brain development show that new neuralconnections continue to form and old connections are strengthened because of repeated thoughts or behaviors. Neural connections that get used tendto last, while those that are not reinforced fade away the use it or loseit principle at work.

Researchers say learning that makes use of repetition tends tobe ingrained deeper and more permanently in the brain, and that the carving ofthese mental pathways helps form the individuals behavioral matrix. You mightbe able to teach an old dog new tricks after all, since old neuron pathways canbe reactivated; the key is behavior modification. However, the biggest challenge might be addressing individualsresistance to change. Most people change only if they want to change, becausethe status quo is comfortably familiar and safe. Brains become wired to adoptthe same behavior, so if someone does not wash his or her hands, he/she may notchange their habits unless behavioral interventions are implemented.

In 2000, a team of researchers led by Larson publishedresearch into behavioral aspects related to handwashing.2 They first answeredthe question of how much handwashing is enough, and whether more frequent orbetter handwashing had an incremental impact on the reduction of risk ofhospital-acquired infections. They concluded, Even in this era of multipleprecautions, several studies in the 1990s have demonstrated that staffhandwashing led to a measurable positive effect on nosocomial infection rates.Hence, continued emphasis on handcare regimens seems justified. If that is the case,however, another challenge that of the handwashing behavior of healthcareprofessionals has proved to be stubbornly resistant to intervention andchange.

Organizational culture may be to blame, says Dion Lerman,CFSP, education and training director for The Handwashing Leadership Forum inPhiladelphia. He points to researchers Sturges and Minor, who say thatorganizational culture has two aspects formal and informal.3 Formal aspects,such as mission statements, policies, procedures and rules, are what supervisorsexpect to enforce and thereby change behavior. It is the informal aspects such as values, norms and assumptions that have more impact on employees andare much more difficult to change.

Everything from peer pressure to social mores can come intoplay to affect hand-hygiene compliance. If a healthcare facility has created aculture that embraces handwashing as the right thing to do for its patients andits employees, chances are it is more effective than a culture that leaves handhygiene as an afterthought. Do physicians wash their hands and set a goodexample for medical students? Do nurses wash their hands to set a good examplefor nursing assistants? Are dietary and housekeeping personnel given the sameopportunities for education about proper hand hygiene?

Does management provide all departments with the resourcesthey need to encourage and reward hand hygiene? Many times, there is also adichotomy between knowledge and behavior. Knowledge itself does not changebehavior, said researcher Don Kirkpatrick in the 1950s. Educator Benjamin Bloom suggested that education needed to embrace threeprocesses in order to be effective: cognitive (knowledge-oriented); affective(emotionoriented); and psycho-motor (skill-oriented).

For supervisory personnel, cognitive processes abouthandwashing may be sufficient, but for those at the operational level, it may benecessary to address motivation and skill issues. Lerman describes elements of aclassic learning theory:3

  • Unconscious incompetence is the ignorance of poor behavior

  • Conscious incompetence is the teachable moment during awareness of bad behavior

  • Conscious competence is the learning and practice of new behavior

  • Unconscious competence is the internalization and performance of new behavior

This model dictates that the culture itself must be changed, because within the context of the existing culture, the current behavior is appropriate. Lerman says, Culture does not change by mandate, butthrough the substitution of a new value system that is comprehensive andintegrated. He adds that a successful transformation must replace:

  • Tradition with innovation (willingness to learn and adopt new behaviors)

  • Hierarchy with teamwork (replacing rigidity with a cooperative respect)

  • Anti-authoritarian reaction with empowerment (taking proactive responsibility)

  • Endurance with persistence (using technology to remove some of the physical labor)

The Handwashing Leadership Forum suggests the following tipsto accomplish good handwashing behaviors:

  • Resources should be designed to communicate cross-culturally, using visual, not verbal techniques

  • Resources produced to change worker behavior must consciously model the desired traits and behavior within a context that is clearly a real-life situation

  • Concrete, rather than abstract concepts and examples should be presented; the direct effect of lack of handwashing and infections onworkers, their families, patients and communities must be demonstrated

  • Personal responsibility should be reinforced

  • Assumptions about the level of workers knowledge should be avoided

  • Workers should be depicted as solving problems themselves, rather than under the direction of a supervisor or outside authority

In her 2000 paper, Larson reported, In 15 studies designed toimprove handwashing, gloving, and universal precaution practices amonghealthcare professionals, interventions included various educational strategies,performance feedback, and environmental controls or modifications, but only twoof the studies reported any sustained behavioral effects on rates of infection.2

Larson found that supervisors and their organizationsculture can be more influential than expected. She writes, Despitereinforcement and monitoring by hospital leadership, the intensity ofimplementation and commitment to components of the intervention varied in thehospital across units and departments (depending upon individual leaders) andover time. Despite this, the major components of the intervention (i.e.,the integration of a handwashing performance competency for all staff, andcontinued, visible administrative support for handwashing and other infectioncontrol practices) have become an integral part of the organizational climateand are continuing.

In Larsons study, the investigators wanted to determine ifinvolving toplevel management in an administrative intervention that emphasizedthe creation of an organizational culture in which handwashing was a clearadministrative expectation, would have an impact on handwashing compliance. The study was conducted at two 250-bed hospitals in the samemetropolitan area, and both facilities employed a full-time infection controlpractitioner (ICP) responsible for surveillance of nosocomial infections andstaff education. Although the handwashing intervention was hospitalwide,logistics necessitated measuring handwashing frequency in an adult ICU andneonatal ICU. Undetectable counting devices were placed inside every soapdispenser on four units, and each time the soap was dispensed, the device wastriggered to record one count. An independent data collector recorded thereadings from all counters on a routine basis and the counters were reset aftereach reading. Handwashing frequency was measured at baseline, implementation andfollow-up.

Implementation of the intervention was guided by Scheinsbehavioral framework4 through the use of five mechanisms: attention, reaction tocrises, role modeling, allocation of rewards, and criteria for selection anddismissal. For the intervention, top managers and medical/nursing leaders(including the CEO, vice president of nursing, hospital board and medical staffboard) agreed to provide active support for a culture change that highlightedand enforced expectations for handwashing compliance. Twenty managers wereidentified as clinical leaders who would develop and oversee the intervention,and from that, a smaller group met with the study researchers to identifyspecific interventions and strategies that aligned with Scheins mechanisms.They are:

  • Attention: Leaders communicate their values and concerns bytheir choices for praise or criticism (i.e., a letter from the CEO stating thefacilitys commitment to handwashing; a handwashing fact sheet is developed and distributed to all employees; an article describing proper hand hygiene protocol is published in the facility newsletter; samples of hand-hygiene products are distributed; infection-rate data is distributed)

  • Reaction to crises: Leaders can reinforce values and desired behaviors in times of crisis to increase the potential for organizational learning (i.e., outbreaks of VRE and MRSA above the facility thresholdare used as opportunities to review and reinforce handwashing)

  • Role modeling:Leaders communicate values by their own actions (i.e., handwashing by leaders isvisible to all employees)

  • Allocation of rewards: Leaders communicate values bythe selection of individuals for formal recognition (i.e., handwashingcompetency is recognized and rewarded)

  • Criteria for selection and dismissals:Leaders make explicit the behaviors expected by favoring those in compliance anddismissing those who are not (i.e., all new hires receive and sign a copy of the handwashing fact sheet and receive sample handhygiene products)

The countingdevices recorded 860,567 handwashes during eight months of monitoring; 477,680 in the intervention hospital and 382,887 from thecomparison facility, and handwashing frequency increased at both facilities (thenumber of soap-dispensing episodes increased from 42.6 per patient-care day to116.6 during the follow-up stage). A total of 236,989 patient-care days weremonitored; records showed 29 nosocomial infections with VRE and 44 with MRSA inone hospital and 80 VRE/55 MRSA in the other hospital. The study showed nosignificant differences in MRSA rates between the hospitals during either theimplementation or the follow-up phases, but the intervention hospital showedsignificantly lower rates of VRE during both implementation and follow- up.Rates of MRSA from baseline to follow-up in the intervention hospital showed a33 percent decrease and a 31 percent increase in rates in the comparisonhospital. Rates of VRE decreased 85 percent in the intervention hospital frombaseline to follow-up rates and decreased 44 percent in the comparison hospital.In the intervention hospital, no outbreaks of VRE or MRSA were detectedthroughout the study period, while the comparison hospital experienced twooutbreaks.

Larsons team acknowledges a survey5 showing that 1,716healthcare workers thought that the No. 1 predictor of adherence to universalprecautions was a safety climate in the facility, including a strong andovert management commitment to safety, as well as formal training. Larsons team says it believes in a trickle-down effect. Weundertook this study because we became persuaded by the evidence that anyintervention that is aimed primarily at the individual practitioner to theexclusion of the organization, even if it is grounded in sound behavioralscience theory and is well designed, will not produce cost-effective,sustainable results.

The investigators emphasized that handwashing in theintervention hospital did not increase immediately, only to die off quickly; instead, changes were modest but continued and increased overtime. Its a buy-in pattern, the researchers said, indicative of anorganizationwide diffusion that becomes sustained as cultural norms aremodified.

They summarized, Influencing habitual behaviors, such ashandwashing, is extremely difficult and has proven to be a resistant challengein healthcare settings. In this study, we found a temporal association betweenan organizational intervention and changes in estimated handwashing frequencyand infection rates. If these results are repeated in other settings withrigorous methods and formal, randomized clinical trials, this simpleintervention could offer new hope for a highly intractable problem. The resultsof this study, which point to a significant and sustained increase in frequencyof handwashing with a concomitant reduction in rates of VRE and MRSA, aresufficiently promising to warrant further study in other settings. Interventionsdirected toward changing organizational culture and expectations may offer asuccessful approach to both improved handwashing and other clinical practices.

In a paper that predated the behavioral intervention project,Larson spearheaded a year-long clinical trial in an ICU that was designed toincrease the frequency of handwashing through use of multifacetedinterventions.6 While significant improvements were noted on the unit during thestudy, Larson reported that within two months, handwashing practices had returned to baseline, despiteintensive and ongoing efforts to address the components of the behavioral changemodel: predisposing (knowledge, beliefs, attitude); enabling (skills,equipment); and reinforcing (peer support, feedback). The intervention wasnot only very expensive and labor intensive; it was also ineffective andshortlived, she wrote.

Larsons team acknowledged, Mounting evidence indicatesthat behavioral interventions, even when based on sound social science theory,may have only a limited effect on ingrained public habits, such as hand hygiene.

In this paper, Larson and three other researchers studiedpredisposing, enabling, and reinforcing factors to improve frequency ofhandwashing. Over the course of a year, multifaceted interventions includingfocus group sessions, installation of automated sinks, and feedback to staff onhandwashing frequency were implemented in an ICU. Variables observed werehandwashing frequency and self-reported practices and opinions abouthandwashing. During 301 hours of observation, 2,624 handwashings were recorded.The proportion of times hands were washed varied by indication, ranging from 38percent before invasive procedures to 86 percent for dirty-toclean procedures (p< 0.00001). The researchers concluded, Although there were somesignificant differences between experimental and control units in handwashingduring the study, these differences had returned to baseline by the two-monthfollow-up. There were no significant differences in self-reported practices andopinions from before to after intervention, nor between units. Intensiveintervention, including feedback, education, and increased sink automation, hadminimal long-term effect on handwashing frequency.

In 1998, Larson and Edna Kretzer, RN, MS, CFNP published apaper7 that studied several behavioral theories within the context of HCWbehavior. They wrote, Compliance is the degree to which a person adheres toadvice. Healthcare workers have cited various reasons fornoncompliance with handwashing and use of barrier precautions: insufficienttime, inaccessible handwashing supplies, irritating handwashing agents, lack ofknowledge of protocols, forgetfulness, interference with provider/patientrelationships, altered tactile sensation, and restriction of movement. Noncompliance with universal precautions has been reported tobe significantly correlated with sex (male healthcare workers are lesscompliant), worker perception of patient needs, highly risk-taking personality,and the safety climate of the institution. Compliance is also associated withcertain sociodemographic and attitudinal factors, such as profession, type ofclinical setting, and geographic location. They continued, At the grouplevel, active involvement and encouragement from key staff members may help topromote and sustain behavioral changes in healthcare settings. Furthermore, administrative sanctions and leadership have beenassociated with improved compliance rates. This suggests that both external(environmental) and internal (personal) variables must be considered whenplanning interventions to improve compliance.

These theories can help healthcare professionals understandbehavioral triggers:

  • The Health Belief Model (HBM) says that ones actionsdepend on the perceived susceptibility to a health threat, the perceivedseverity of the threat, and the belief that a particular health recommendationwould be beneficial without risk. For example, one would adhere to universalprecautions if one believed that no one was susceptible to a serious infectionduring a patient interaction and expected to contract the infection if noprotective measures were taken; cues in the environment would trigger use ofthese measures. For example, the individual may ask, Am I aware that a threatto my health exists if I fail to wash my hands regularly? while the organization may ask, Do we understand therelationship between handwashing and spread or risk of infection?

  • The Theory of Reasoned Action (TRA) and the Theory ofPlanned Behavior (TPB) are based on the assumption that humans are rational,make systematic use of information, and consider the implications of theiractions before engaging in a behavior. The theory suggests that one who believesthat a behavior will lead to a positive outcome will hold a favorable attitudetoward it.

  • Self-efficacy is defined as a persons judgment of theircapability to organize and execute courses of action required to attain types ofperformances. It can be influenced by attainment, observatory experiences,verbal persuasion and physiological state. Thus, personal perception accountsfor the effort and persistence applied to a specific behavior. The individual may ask, Do I believe that I can contributeto the reduction of infection? while the organization may ask, Do we washas frequently as expected and as carefully as prescribed?

The researchers say, No behavioral theory has been shown toconsistently predict behavior, but many theories share similar constructs thatcould be integrated into an intervention to improve infection control practices.The key is understanding what the individual might be thinking, and whether ornot that thought is aligned with the facilitys values. Individuals may think,I might wash my hands more frequently if my efforts were supported. Do I value the reductionof infection enough to be committed to changing my behavior?8 The researchersadded, A healthcare worker with a high sense of self-efficacy towardinfection prevention who also understands and believes in the organizationspreventive goals will attempt to own, be committed to, and will strive toattain those goals.

The researchers recommend the following when planning atheoretically based intervention for improving infection control practices:

  • Incorporate beliefs, perceivedhealth threat, cues, self-efficacy, attitude, subjective norms, perceivedbehavioral control and intentions into any planned interventions.

  • Consider factors in the work environment most likely to maximize effectiveness, including communication, participation, involvement of organization leaders, fairness, mutuality, respect and external/ internal re-enforcers

  • Assess individual and group readiness before selecting any interventions

  • Track and monitor processes in an ongoing evaluation of the interventions

  • Avoid use of words such as compliance, replacing them with phrases that promote active participation and internalization, such as enhancing practice

Researchers have long known the factors that discourage handhygiene. Noted hand-hygiene expert John Boyce, MD, says lack of awareness aboutsituations that call for handwashing, personal and organizational attitudestoward handwashing, and various logistical barriers all contribute tonon-compliance.9 Didier Pittet, MD and a team of researchers were the first todocument that a high workload is associated with poor handwashing compliance.10

In their paper, Factors influencing handwashing behavior ofpatient care personnel, researchers Larson and Killien studied the habits of193 healthcare personnel.11 These workers reported that the No. 1 reason forwashing ones hands was the prevention of spread of infection amongpatients but the biggest factor against hand-hygiene compliance was cited asbusy-ness. The study reported that individuals who washed infrequently(less than eight times per day) placed significantly more value ondetrimental effects of frequent handwashing on their own skin and on thehandwashing practices of their work colleagues than did individuals who washedfrequently (more than 16 times per day). The study added, Frequent andinfrequent washers did not differ significantly in their values regarding thefactors favoring handwashing. Identifying factors that are determinants ofwhether one decides to wash ones hands or not are important in planningintervention strategies to improve practice. It appears that more emphasisshould be placed on minimizing deterrents (especially detrimental effects onskin and peer pressure) rather than on emphasizing the importance ofhandwashing.

Enter the Machines

If removing deterrents is the answer to increased handhygiene, the question is, what makes it easier for HCWs to comply? Industry, byway of technology, thinks it has a solution. One of the earliest ways to preventcross contamination was to eliminate the necessity of touching sink faucets andpaper towel dispensers. Enterprising companies engineered touchlesssystems without handles. Electronic components emit a continuous infrared beamthat, when interrupted by a pair of hands placed under the faucet, will triggera stream of water. Removing the hands turns the water off. In a similar vein,soap dispensers and paper towel dispensers housing similar sensors willdischarge their contents without the user having to touch a level or a crank.Bringing touchless technology full circle, some systems offer full integrationfor streamlined handwashing without ever touching a surface.

A number of different systems is available. Best SanitizersInc. offers its safeHANDS Wash Station, designed for minimum splash anddischarging water and pre-measured applications of soap and atomized sanitizer.World Dryers series of Automated Hand Wash Stations leads users through acomplete hand sanitation process that includes soap, tempered water, and warmair or paper towel drying in a procedure that takes less than a minute. Infection Control Systems Inc.s Touchless DispensingSystems With GermFighter is a line of automatic, touchless systems that dispensean instant hand sanitizer for killing germs without the use of water, papertowels or drying. In a similar vein, Kimberly-Clark Professionals no-touchdispensers fight cross contamination. The companys SANITOUCH NoTouch HACCPRoll Towel Dispenser allows users to grab a paper towel without touching cranksor levers, and the SANITOUCH Skin Care Dispenser uses an infrared sensor toautomatically deliver the right amount of soap to the hands. Georgia-PacificsenMotion series of automatic, touchless technology- driven paper toweldispensers promotes good hygiene by reducing the number of touch points in therestroom and lowers the risk of cross contamination when drying hands. Ecolabs Digitizer is a special gel soapdispenser that features an LCD counter to help monitor the number of handwashings for each employee group.

Putting an End to the Splash-and-Dash Technique

Since much of what constitutes handwashing these days is aquick (and frequently soapless) rinse under water, various systems incorporate atiming device that not only dispenses a cleansing agent, but tells the user whenhands have been washed for a satisfactory amount of time to facilitate adequatescrubbing and rinsing.

Last fall, GoJo Industries introduced the iNXT TouchFreeDispensing System which features the Portion Rx advanced measurement technology,providing end-user control for dispensing based on efficacy requirements forportion management. In conjunction, the iNXT Signol device includes a hardwareand software package that enables monitoring of hand-hygiene practices inapplications in facilities where tracking and reporting are required. The deviceemits an audible signal to let users know when the 20-second handwash sessionis up, so there is no guesswork about the duration of the wash.

Giving HCWs a pass or fail system in the restroom is the CleanHands Handwashing Monitoring System, which is equipped with an RF receiverattached to the wall of the entrance of the lavatory. The employee wears a badgethat is detected as he enters the room, and the signal will be recorded into thecentral computer system. When the person is ready to wash his hands, he appliesan amount of soap and rubs them vigorously together to form a reasonable amountof lather. He will place his hands under the Clean Hands Monitor, at which areal-time video of his hands will appear on the left of the screen. The monitortakes several seconds to allow time for the antibacterial agents to take effect.Then a colorized digital image is displayed on the right side of the screenshowing the individual the areas with adequate soap, which appear as green, andthe areas where more soap needs to be applied, which appear as red. The monitorwill also display a pass or fail. If the person fails, he can rubhis hands together more thoroughly and test again, or he can add more soap andrepeat the process. Once a pass has been issued the person can return towork. The data is stored and is easily accessible by supervisors wishing tocheck the number of fails registered and actually view the stored image ofthe handwashing failures.

The HyGenius handwashing management system attaches to anyexisting handwashing sink or automatic wash system and is designed to verifyindividual handwashing compliance. The system administers a step-by-step, time-and termperature-controlled was automatically, without the user having to touchfaucet handles. The water flows to allow proper and thorough wetting, then isautomatically stopped while the built-in display instructs the user through thedispensing of soap, lathering, scrubbing, rinsing and drying. HyGenius alsoincorporates wash due reminders throughout the workday to ensure regularhandwashing by each user. Any time a healthcare worker misses a handwash where minimum frequency requirements are in place, an audible tonewill sound and a built-in indicator light will flash while the system displaysthe persons ID number for prompt notification.

In case these systems are a little too Big Brother for afacilitys tastes, the Amron Corporation has created a system called HandHygiene Prompts (HHP), a computer-based device that collects data from sensorswhich report room exit and entry, toilet use and hand hygiene compliance. Fromthese data, HHP determines if a HCW should wash their hands, and plays apre-recorded voice message over a loudspeaker to Please wash your hands ifthey do not. According to Amrons Stephen Lane, PhD, the system isnon-intrusive, as users are not identified by badges or tags; it isnon-threatening, because users are not penalized for not washing; it isnon-coercive, because the device reminds, not commands; and it is neitherstigmatizing nor invasive, as users are not identified as having dirty hands,and no cameras or microphones invade their privacy.

Amrons work in handwashing behavior modification throughverbal messages has been funded by the National Institutes of Health for thepast seven years, and successful clinical trials at Johns Hopkins UniversityHospital and Biloxi Specialty Hospital point to increased hand-hygienecompliance and decreased nosocomial infections.12

Initially, HCWs didnt like to hear the voice, but theyrealized it was reminding them to do something they know they are supposed todo, Lane says. They said, All right, Ill do it. That iswhat we are counting on. We are not coercing anyone to do it. They neglect to do it;they dont refuse to do it. So its a gentle yet effective reminder.

When people first hear the voice, they cant believetheir ears, says Amrons Kevin Strauss. Then they say, Wow thisreally works. ICPs have told us it is exactly what they need. They alwaysseem to be a warden for handwashing and with HHP, they dont have to be thebad guy anymore.

According to Lane, there have been no commercial sales of HHPyet, but hes hopeful hospitals will look past the $10,000 cost per 10-roomward and recognize they can save money in the long-term.

If HHP saves you two nosocomial infections per month, whichis what our experimental study results indicated, it pays for itselfimmediately, Lane says. The difficulty is that hospitals dont seem tohave a capital budget to buy something like HHP, related to not having a lineitem in their budget for nosocomial infections. But they pay for increasedlength of stay due to nosocomial infections.

Do the Machines Work?

Most clinicians say anything that facilitates properhandwashing is worth a try, and machines make it a no-brainer situation.Meritech, Inc. offers the CleanTech automatic handwashing systems designed toremove microorganisms from hands without contact. Users insert their hands intotwo open cylindrical chambers. As the hands enter, an optical sensor initiatesthe cycle; the cylinders begin rotating and hidden nozzles automatically spray awater and antibacterial solution combination. The system then rinses withnon-irritating, high-pressure sprays of water. Hands are then dried with papertowels, air dryers or with a dryer incorporated into the system. The system is designed to ensure consistent water pressure,water temperature, soap usage, cycle length and skin coverage, and laboratorystudies have shown a consistent bacteria reduction between 99 and 99.9 percentfor the 12-second cycle.

In a 1990 study of the efficacy of handwashing machines, twoMeritech systems were installed in a four-bed patient care area of an ICU.13This was compared to another patient-care area that had a foot-operatedantimicrobial agent dispensers as well as clean sinks for handwashingoperated by foot pedals. All HCWs were observed to use the automated system 75percent of the time, vs. 67 percent compliance in the manual hand-hygiene area. Also studied were only nurses using the automated areavs. the manual area for 40 days each. The study showed that the automated systemdecreased the total organism count compared to manual handwashing over thecourse of the nursing shift.

In a 1990 study, Larson and fellow researchers from JohnsHopkins University examined the effects of an automated sink on handwashingpractices and attitudes of HCW in a postanesthesia recovery room and a NICU intwo tertiary care hospitals.14 An automated sink was installed to replace a handwashing sink for about five weeks; the sink was then crossed-over for anequivalent time period to the other location. Handwashing practices of all HCWs were observed in threetwo-hour observation periods per week, amounting to 1,610 handwashes.

Handwashing practices differed significantly by site. For bothsites, hands were washed significantly better but significantly less often withthe automated sink (all p less than .001). HCWs expressed negative attitudes,however, about certain features of the sink, and these negative attitudesincreased over the study period. The investigators concluded that Automateddevices must be flexible enough to allow adjustments based on staff acceptance.Application of new technology to improve hand hygiene requires a multifacetedapproach to behavior change.

The Handwashing Stations Role in Cross Contamination

As experts debate the role inanimate objects play in thetransmission of infectious agents, few would doubt that the contamination ofenvironmental surfaces such as handwashing sinks is a major issue.

Clearly inanimate surfaces play a role, particularly withorganisms such as VRE and C. difficile, says Elaine Larson. But it seemspretty clear that direct contact (i.e., person-to-person touching) remains themost important mode of cross transmission. Nevertheless, housekeeping andenvironmental cleaning seem to have taken too much of a back seat and we need tore-emphasize the great importance of keeping the healthcare setting (as well asthe people) free of a large microbial bioload.

Various studies have demonstrated infections stemming fromfaucet aerators15, splash from sink drains16 and handwashing machines17 In thepaper, underwritten in part by Georgia-Pacific, Environmental surfacecleanliness and the potential for contamination during handwashing, a team ofresearchers determined the organic, microbial and staphylococcal load on contactsurfaces (faucet handles, soap dispensers and paper-towel dispensers) in fourBritish hospitals that could be touched during handwashing, and to evaluatehand-mediated cross-infection.18 Manual faucet handles had a higher mean ATPlevel than manual soap or paper-towel dispensers, yet the latter were shown topresent some presence of bacterial contamination. The study showed thatcontamination of hand-contact surfaces could act as a reservoir formicroorganisms and could contribute to hand contamination before or after handwashing. In addition, the sink environment and its organic matter couldserve as a breeding ground for potential pathogens.

The researchers concluded, Faucet handles have long beenidentified as a possible site for cross contamination between users, with thesuggestion of either automatic faucets or the turning of faucet handles withused paper towels.19-20 Although overall, paper-towel dispenser exits carriedthe lower levels of contamination, the results are of prime concern as they arethe final surface that may be touched during handwashing/ drying immediatelypreceding patient contact, and therefore may to some extent be more important.

How Clean is That Dispenser, Anyway?

A number of studies confirm that paper-towel dispensers areimplicated in the transmission of infectious agents. In the paper, Bacterialtransfer and cross-contamination potential associated with paper-toweldispensing,21 researchers from the United Kingdom and the United Statesstudied the transfer and cross-contamination potential between hands, towels,and dispenser exits if one or more is contaminated using bacteria representativeof the skins flora.

They wrote, Hand drying is the critical last stage of thehandwashing process and needs to be implemented in a way that reduces, ratherthan increases, the risk of cross-contamination.22-23 This requires that thedrying is effective and that contamination of hands does not take place.

However, concerns are now starting to be expressed about thedispensing of handwashing materials and the functionality of dispensing systems.24-25 The three methods frequently used for hand drying arehot air dryers, cloth towels, and paper towels.26-28 Whereas papertowels are recognized as the most hygienic method of hand drying, paper towels,exits29 and dispensing mechanisms30-31 (levers and mount location), have beenidentified as potential sources of contamination, especially for paper towelshanging in sink splash zones.

The researchers used a generic wall-mounted paper-toweldispenser and a variety of different paper towels. Volunteers with either cleanor contaminated hands were asked to remove, using a range of protocols, towelsfrom dispensers which were either clean or contaminated. Previously cleansurfaces were then microbiologically tested. The investigators found thatrecoverable bacterial transfer rates from a contaminated hand to clean dispenserexits ranged from 0.01 percent to 0.64 percent, depending on the bacteria usedwith an even higher transfer rate for clean towels. The reverse transfer, fromcontaminated exits to clean hands, was between 12.4 percent and 13.1 percent.The results indicate that zig-zag transfer of bacteria between paper-toweldispensers and hands can take place if either one is contaminated, and should beconsidered in the design, construction, and use of paper-towel dispensers.

The investigators wrote, This study has shown that even manualpull disposable folded towels and towel dispensers that are considered handsfree or touchless can become contaminated if the surfaces at the dispenserexit are touched. This usually occurs when the paper towel is not cleanlydelivered to a user, and this varies considerably depending on the compatibilityof paper towel and dispenser combination.21 The total number of bacteriaisolated from the dispenser exits after freeing a jammed towel with acontaminated hand was relatively low but should be viewed within the context ofthe number of times per day this activity may need to be carried out. It is alsoimportant to note that in some cases, although the minimum infective dose can bevariable, only small numbers of pathogens, especially for intestinal disease,may be required to cause illness. A number of these pathogens are known to causeoutbreaks in hospitals, therefore, even the low estimates obtained in thepresent study still allowed for sufficient bacteria to be transferred for themto exceed the minimum infective dose for a number of human pathogens. This wasparticularly true of the numbers transferred from wet, contaminated hands to drytowels remaining in the dispenser. The type of contamination demonstrated inthis study, coupled with the survival potential of some pathogens causinghospital acquired infections, could also assist in the spread of organismswithin the hospital environment.

They continued, There was an even greater transfer of boththe resident and transient bacteria to the towels pulled or remaining within thedispenser. Paper towels with damp patches or spots may, in addition to beingaesthetically unappealing, present an infection risk. Emphasis on decreasingaccidental contact by educating and training healthcare and food workers mayreduce the spread of pathogens and lower the risk of nosocomial infections. Inaddition, this work further highlights the need for careful selection ofpaper-towel types and their dispensers on the basis of functionality.

Handwashing Automation Can Save Time and Reduce Infection

By Jim OConnor

All doctors and nurses know the importance of washing theirhands before and after contact with a patient, but do they always have the timeto do it, and to do it properly?

Its a standard practice, but with busy schedules,complying is not always easy for some professionals, says Dr. Murray Favus,who was director of the Clinical Research Center at the University of Chicagofor the last 19 years.

As an example, he describes the process of making patientrounds along with a small team of interns, residents and students.

Typically, as many as four of us might have patientcontact, shifting a persons position in bed so we can examine his or hercondition or change a dressing. A sink, soap and paper towels are in or nearevery room, but the cleaning process slows us down. If four people have to scrubdown after seeing 15 patients in the morning, thats 60 handwashings.

Favus says everyone wants to follow policy, but no one wantsto slow the teams progress. Not every washing is thorough.

Doctors and staff in the intensive care unit must be even morediligent, he says, pointing out that the sickest people require more frequentmonitoring. They might be the most contagious, or have weak immune systems. Adozen or more doctors will examine or treat a patient in one day. Sometimes theyneed gloves, sometimes they dont. In any case, handwashing before and aftercan be critical.

Automation Could Save Time, Reduce Germs

To accelerate the handwashing process, some medical facilitieshave foot pedals to operate the faucets, or more sophisticated automatic faucetsactivated by sensors.

Not only is automation easier, but eliminating handles alsoeliminates potential cross contamination, he notes. Every time a doctor or nurse touches a handle,germs could be transferred to that handle.

Automatic faucets, also called touch-free faucets, arebecoming increasing common in public restrooms, office buildings, schools,stadiums and other facilities with heavy traffic, and they make sense forhealthcare facilities. Conversions to touch-free have been slow, however, because ofthe cost and the unreliability of some automatic faucets.

Thanks to advances in technology, those barriers aredisappearing.

Earlier generations of automatic flushers and faucets werenot always dependable, and some that are still on the market today have anunacceptable failure rate, says George Patrick Murphy, president and CEO ofTechnical Concepts, a manufacturer of touch-free restroom fixtures. Ourcompanys goal was to develop dependable products that worked every time, andeventually paid for themselves through water conservation and little or nomaintenance.

Last year, Technical Concepts introduced Radius Touch-FreeTechnology, an advanced operating system for flushers, faucets and relatedproducts. Our faucet sensors create a force field that surrounds the faucet,so the users hands dont have to search for the right spot, Murphy says.Water flows as soon as hands approach the faucet, and stop when the hands areremoved.

Companies that supply restrooms with handtowel dispensers aredoing their part to keep restrooms touch-free. The von Drehle Corporation offersa paper towel dispenser activated by a sensor, but says a faster and morepopular product is its center-pull dispenser that has a paper towel sticking outof the bottom like a tail. When it is removed, the tail of another sheetappears. With either system, the user does not have to touch a button or turna crank, says Steve von Drehle, president. Both dispensers provide onetowel at a time, which is enough to dry your hands.

With the combination of these products, the handwashingprocess is not only faster, but nothing has to be touched except a fresh papertowel.

A Quick Return on Investment

Favus sees value in having automatic flushers in washroomsused by patients. Its one less step for a weak patient, he says. Andif the patient needs a nurse or an aid to help him or her go to the bathroom,the assistant can concentrate on helping the patient return to bed withoutworrying about flushing. Again, there is no handle for anyone to touch orcontaminate.