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Handwashing: Problems and Solutions: Part IIby David L. Dyer, PhD
Several studies have indicated that the issue of handwashing non-complianceby physicians is complex. Larson43 points out that operatorcompliance with product use is not only dependent on its clinical performancebut also on its subjective acceptability (packaging, odor, etc.) and on theindividual perception of product harshness with prolonged use. In a review ofthe barriers to handwashing compliance, Springthorpe and Sattar44identified three main obstacles: 1) the amount of time needed for properhandwashing; 2) the convenience and user-acceptability of handwashing andhand-drying facilities, and 3) the condition of the skin barrier. It is clearthat handwashing compliance may suffer in understaffed clinical settings. Staffincreases require increased spending, which in the present era of costreductions by health maintenance organizations may not be achieved easily. Thegreat cost of nosocomial infections to healthcare systems may outweigh anyfinancial benefits recovered through increasing patient/staff ratios andjeopardizing compliance with basic universal precautions.44 Voss andWidmer23 indicate that the time needed to achieve 100% compliancewith present handwashing guidelines could decrease the time available for otherroutine cleaning and disinfection and adversely impact overall patient care. Theauthors further indicated that the use of appropriate instant hand sanitizersmight be a time-effective alternative to handwashing. Such an improvement mightincrease the convenience and accessibility of hand sanitization for physicians.In that study, the 16 hours required for maximal compliance with soap and waterpractices shifted to only three hours when bedside dispensers for instantsanitizers were made available. Care should be taken to ensure that bedsidedispensers are not contaminated with frequent use. A touch-free design for adispenser in such a frequent-use setting is, therefore, desirable; however,design flaws associated with present touch-free systems (based on infrared lightdetection alone) can cause inappropriate product release, which can result inincreased maintenance costs and even in injury to the public in the event thatthe product is released onto the floor.45-47 Such flaws have been alimiting factor to the widespread use of touch-free systems in the US. Animproved dispenser, which releases product based on the detection of both humanbioelectric field and infrared light greatly decreases the chance ofmisdispensing the product. Cost-effective dispensers that incorporate this typeof detection system are anticipated to be available to the medical community byFall 2000.48 Care should be taken to determine the potential fortheir long-term acceptance and utility in different healthcare settings.Automated devices should be flexible enough in implementation and use to allowadjustments based on staff acceptance.49
A significant impediment to proper handwashing is the condition of the hands,in particular whether the product causes painful chapping or dermatitis withfrequent use. Smit, et al.,50 indicated that nursing staffhave a prevalence of hand dermatitis and chapping of about 30%. Larson51reported that although skin damage was apparent in 25% of observed nurses, 86%rated themselves as having some sort of skin problem. Such difficultiesassociated with handwashing and gloving practices can affect compliance and,therefore, increase pathogen carriage on the hands. Because of this effect, theinfection control staff should ensure that any formulation accepted for frequentuse is non-irritating and has a minimal potential for skin sensitization. It isimportant to realize that skin reactive properties of active ingredients are,just as for antimicrobial activity, highly formulation dependent. For example,sodium lauryl sulfate is known to disrupt the stratum corneum water barrier andcan cause hand dermatitis associated with handwashing.52-53 Thisadverse effect is amplified with the use of gloves and in high temperaturesituations54-55 but can be avoided if urea is added to theformulation.56 Another example is benzalkonium chloride, which hasbeen approved for use in a topical antiseptic application at 0.13% v/v57but which can be a dermal irritant at this and higher concentrations.58-59In the context of a formulation containing amphoteric and nonionic surfactantsand allantoin, however, antimicrobial effectiveness is improved with theminimization of dermal irritancy and sensitization.60
Is Staff Education an Effective Solution?
Efforts have also been made to improve handwashing compliance throughphysician and staff education programs. In one study, Dorsey, et al.,61found that minimal intervention via posting of CDC handwashing recommendationsand the distribution of educational material resulted in a noticeable butstatistically insignificant improvement in total handwashing. Interestingly,this study also indicated that nurse practitioners and registered nurses hadsignificantly higher adherence to recommended handwashing between patients thanemergency physicians did. Mayers, et al.,62 observed a nursingstaff for three months, and then substituted the normal hand sanitizer with anemollient based formulation in parallel with implementation of a daily programof feedback to nurses on their handwashing frequency. While no increase inhandwashing was observed upon switching to the emollient-based sanitizer,feedback provided to the experimental ICU increased handwashing frequency to 92%of the required levels and was significantly higher than handwashing in thecontrol unit. A follow up observation, however, indicated that when feedback wasremoved, compliance fell to baseline levels. Similar findings regarding theeffectiveness of education feedback and enforcement have been presented by Conly,et. al.,63 and Dubbert, et. al.64 In thelatter study, education alone produced an immediate improvement in compliance,which declined to baseline four weeks after instruction ended. Because theobstacles to handwashing compliance are interrelated, they may be very difficultto resolve.43 Specifically, changing only one parameter may notchange hand-cleansing behavior in the long term. Ironically, even multifacetedintervention attempts have failed to achieve long-term success. In a prospectivestudy, Larson, et. al.49 implemented intervention, whichincluded focus group sessions, installation of automatic sinks, and feedback tostaff on handwashing frequency. Although some significant differences betweenthe control and experimental ICU units were observed during active intervention,the differences had returned to baseline by the two-month follow-up.
Overall, it seems that a common method in studies that have demonstrated ameasure of even temporary success at improving handwashing compliance is that ofconsistent monitoring of performance followed by feedback. Maintenance of afeedback program is difficult to achieve due to costs and time constraints ofhealthcare personnel. Increasing the community's awareness of the importance ofhandwashing could have a favorable impact on the compliance rate of handwashingin healthcare workers.66 McGuckin, et. al.,67performed a six-week intervention/control study at four community hospitalsconsisting of two general medical/surgery in-patient floors with no obstetric ofpediatric patients and with each hospital serving as its own control. Within 24hours of admission, patients were educated on the importance of asking theirhealthcare workers to wash their hands prior to touching them. The follow-upindicated that 81% of the patients enrolled in the study read the educationalpamphlet on handwashing that was provided, and 57% asked their healthcareworkers whether they had washed their hands. Fifty-seven percent of thehealthcare personnel that were asked responded favorably to the inquiries. Thispatient handwashing education model was found to improve healthcare handwashingcompliance by approximately 34% as measured by increased soap usage. The costsavings estimated with the implementation of the patient-education model in a300 bed 10,000 admission hospital range from $50,000-$60,000 per year, based onapproximately 160 preventable infections per year. Overall, it appears that thislatest method of patient-based intervention meets the need for a sustainableprogram of reinforcement of good handwashing practices in healthcare workers.
David L. Dyer, PhD, is the Research Director, at Woodward Laboratories,Inc. (Los Alamitos, Calif).
Note: Part I of this article can be found in the April issue of InfectionControl TodayÂ®.