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By Ruth LeTexier, RN, BSN, PHN
In thehealthcare setting, handwashing is often cited as the primary weapon in the infectioncontrol arsenal. The purpose of handwashing in the healthcare setting is microbialreduction in an effort to decrease the risk of nosocomial infections.
Hand hygiene can also be a problem in busy health centers and clinics where patientsare seen both in increasing numbers and treated in rapid succession.1 Preventionand control of infectious activities are designed to limit the spread of infection andprovide a safe environment for all patients, regardless of the setting.2 Inlight of the emergence of antibiotic resistant organisms, effective infection controlmeasures, such as handwashing, are essential to prevention.
At a recent Global Consensus Conference, participants were charged with the overallpurpose of achieving consensus on infection control practice across healthcare settingsand international boundaries related to caring for patients with methicillin-resistant Staphylococcusaureus (MRSA) and vancomycin-resistant Enterococci (VRE). The conference provided amajor opportunity for professionals and scientists in the infection and prevention controlfield to discuss trends and develop strategies for best practice. The aim was to examinethe infection control problems associated with these antibiotic-resistant organisms (AROs)and to consider possible solutions.3 One estimate places the direct cost ofnosocomial infections caused by six different strains of AROs to be minimally $1.3 billion(1992 dollars)/year in the US.4 According to the Center for Disease Control andPrevention (CDC), each year an alarming 2,400,000+ nosocomial infections occur in the USalone. They are estimated to cause directly 30,000 deaths and contribute to another 70,000deaths each year. Nosocomial infections cost over $2,300 per incident and $4.5 billionannually in extended care and treatment.
The goal of the Global Consensus Conference was to focus on specific issues that comeunder the direct influence of infection control professionals. Among the issues of focuswas hand hygiene. Participants in the conference started with the premise that theultimate goal of cleansing the skin of care providers, regardless of specific productused, is to prevent the transmission of infection, including AROs, from their hands. Skinworkshop final recommendations included:
1. Hand hygiene is the single most important procedure for preventing the transmissionof AROs.
2. Evidence suggests that the removal of AROs from hands with soap/detergent and wateris less effective than with the application of an antiseptic agent.
3. An antiseptic product shall be used in high-risk areas, with high-risk patients, andwith known ARO patients. High risk areas may include:
--Receiving multiple antibiotics or repeated treatments
--With prolonged hospital stay
--With frequent admissions
4. High-risk areas and high-risk patients shall be identified by regular assessment.
5. Risk assessment for acquisition/transmission of AROs may include patientsurveillance cultures.
6. In the absence of sufficient handwashing facilities and where there is no visiblesoil on the hands, an antiseptic product formulated for use without water shall be used.In the absence of sufficient or adequate handwashing facilities where there is visiblesoil on the hands, soil must first be removed by some means (e.g., rinsing,mechanical, rubbing, and wipes) before use of an antiseptic product formulated for usewithout water.3
The CDC has identified handwashing as the single most important means of preventing thespread of infection.5 The premise of the handwashing CDC guideline is infectioncontrol. The CDC recommendations for handwashing are as follows:
In the absence of a true emergency, personnel should always wash their hands:
1) Before performing invasive procedures (Category I).
2) Before taking care of particularly susceptible patients, such as those whoare severely immunocompromised and newborns (Category I).
3) Before and after touching wounds, whether surgical, traumatic, orassociated with an invasive device (Category I).
4) After situations during which microbial contamination of hands is likely tooccur, especially those involving contact with mucous membranes, blood or body fluids, andsecretions or excretions (Category I).
5) After touching inanimate sources that are likely to be contaminated withvirulent or epidemiologically important microorganisms; these sources includeurine-measuring devices or secretion collecting apparatuses (Category I).
6) After taking care of an infected patient or one who is likely to be colonizedwith microorganisms of special clinical or epidemiologic significance, for examplemultiple-resistant bacteria (Category I).
7) Between contacts with different patients in high-risk units (Category I).
For routine handwashing, a vigorous rubbing together of all surfaces of lathered handsfor at least 10 seconds, followed by thorough rinsing under a stream of water isrecommended (Category I).
The aim of handwashing is to remove microorganisms from the hands, preventing theirpotential transfer. It is known that organisms survive and multiply on human hands,creating the opportunity to infect others or the host.6 Handwashing reduces thenumber of transient organisms on the skin surface. Although hands cannot be sterilized,most transient organisms can be removed by 30 seconds of proper scrubbing with soap andwater. Proper scrubbing would include vigorous motion with the hands rubbing together andfingers working in between the finger web space and inclusive of the dorsal and ventralsurfaces of the hands. Microbes that reside in sweat ducts and hair follicles of the skin,however, cannot be dislodged readily. Surveys show that one in five medical professionalscarry potentially pathogenic antibiotic-resistant pathogens on his or her hands.Handwashing by medical professionals occurs at only 30% of the ideal rate. Failure to washone's hands before and after each patient contact is probably the most importantcontributor to the spread of infections.7 These microbes pose a threat topatients with reduced defenses, so scrubbing with an antiseptic prior to contact withthese patients is usually recommended.
In one study, hospital-acquired infections were reduced 25% by handwashing with soapplus antiseptic compared to a control group who washed with soap alone.7 Theabsolute indications for handwashing with plain soaps and detergents versus handwashingwith antimicrobial-containing products are not known because of the lack of well-controlled studies comparing infection rates when such products are used.5
The effects of handwashing in the prevention of disease transmission from person toperson are undeniable; however, the goal of effective compliance remains unmet.
Education and training of staff has been a central focus of infection control programswith marginal impact. Compliance testing devices may spark awareness in the healthcarework force. The effects of verification and feedback as a mechanism for increasing theprobability of handwashing in the clinical setting appear to be quite dramatic. ComplianceControl Center (Forestville, Md) conducted a study with the intent to measure the impactof individual measurement and verification of overall handwashing compliance. At eachlocation, each individual employee for whom handwashing was deemed critical to theprevention of infection and cross contamination either chose or was assigned an individualand unique verification number to be used with the Compliance Control electronichandwashing verification system (e.g., HyGenius) throughout the study. In each ofthe locations, despite the fact that both supervisors and employees expressed that theybelieved they were doing a good job of handwashing, in actuality, observed handwashingfrequency was low during the observation period. The overall average was 68 handwashingevents per location per week, which resulted in an average of less than one handwash perday per employee.
During the next phase or pre-reporting phase, a time in which the electronic deviceswere installed, handwashing frequency increased by an average of 214% going from 68 in theassessment phase to 213.63% in the pre-reporting phase. The results were likely due to thefact that a means for handwashing measurement requiring individual employeeself-identification was introduced at each site. For a period of 35 weeks, a sustainedaverage of 603 handwashes per week was performed in the study locations. On average,through the conclusion of the reporting period, there was an 890% handwashing rateincrease over the initial observation period measurements. This study indicates thatreinforcement and regular performance feedback using empirical data significantly improveshandwashing compliance.8
While the healthcare worker may have the convincing data or argument for handwashing asan infection control preventive activity, handwashing remains an activity ofself-monitoring. Barriers to effective monitoring may be related to education, level ofawareness, the development of an aseptic conscience, lack of motivation, lack offacilities such as access to sinks, soap, antibacterial detergents, time, etc. If oneaccepts handwashing as the primary weapon in the infection control arsenal, then personalchoice for handwashing rests with the individual foot soldier in the battle against thetransmission of infection or disease.
Ruth A. LeTexier, RN, BSN, PHN, is a nurse educator and Program Director of SurgicalTechnology at Northwest Technical College (East Grand Forks, Minn).
1 Gould DJ. Giving infection control a big hand. Community Nursing Notes. 1997;15:3-6.
2 Stucke VA. Microbiology for Nurses: Application to Patient Care. 7th ed. London: Bailliere Tindall.
3 Global consensus conference: final recommendations. AJIC. 1999;27:503-513.
4 US Congress Office of Technology Assessment. Impacts of Antibiotic Resistant Bacteria. OTA-H-629. Washington (DC): US Government Printing Office; 1995 September.
5 Garner JS, Favero MS. CDC guidelines for the prevention and control of nosocomial infections. Guideline for handwashing and hospital environmental control. AJIC. 1986;14(3):110-115.
6 Reybrouck G. The role of hands in the spread of nosocomial infection. J Hosp Infect. 1983;90,30,63-64.
7 McKane L, Kandel J. Microbiology Essentials and Application. 2nd ed. McGraw-Hill; 1996:362;683.
8 Compliance Control Center website: http://users.aol.com/comontrol/cci4.htm.
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