This month's continuing education article on "Hand Dermatitis" prompts us to consider that, in addition to the high risk of hand dermatitis among wound care practitioners, it is our hands that are the major transmitters of potentially harmful bacteria. Therefore, we must increase patient safety by improving our hand hygiene (HH).
Hand Washing: The Need for Evidence
In 1847, Hungarian physician Ignaz Philipp Semmelweis advanced the theory that hand washing with chlorinated lime solutions was a way to reduce nosocomial infection.1 Puerperal fever was common in mid-19th-century hospitals with a mortality of 10% to 35%. Despite evidence indicating hand washing reduced mortality to less than 1%, Semmelweis' observations were rejected by the medical establishment.1 Some physicians were offended at the suggestion that they should wash their hands. Semmelweis' practice earned widespread acceptance only years after his death, when Louis Pasteur confirmed the germ theory and Joseph Lister operated, using hygienic methods, with great success.1
Later, during the Crimean War (1853-1856), Florence Nightingale's legendary triumphs in patient safety during this conflict have been well documented. She encouraged surgeons to practice HH and demonstrated that safe food and water and a clean environment could decrease death rates in military hospitals.
Hand-Washing Patient-Centered Research
Currently, the Centers for Disease Control and Prevention, The Joint Commission, and the World Health Organization (WHO) recommend several strategies to improve HH with interventional, observational, and other measurement techniques. Any interventional program must include a continuous quality improvement program based in advancing and learning from the organization's efforts in HH and patient safety. When utilizing the principle of observation to measure or improve HH, privacy is always a consideration. The Just Clean Your Hands program of Public Health Ontario Canada is an evidence-based program established in 2008 to improve compliance with HH in healthcare settings to prevent healthcare-associated infections (HCAIs) and promote patient safety. The HH program's instructions state, "The observer must conduct observations openly, without interfering with the ongoing work, and keep the identity of the healthcare providers confidential." There are no identifiers or names recorded on the observer tool.2
A recent study on bacterial contamination of hands by medical care specialty found the highest bacterial contamination on the hands of healthcare workers was from rehabilitation units. A 6-week preintervention and postintervention study, with a 3-month follow-up using a patient education model, was conducted in a 24-bed inpatient rehabilitation unit located in an acute care hospital. Thirty-five patients were enrolled in the intervention phase of the study after agreeing to ask all healthcare workers who had direct contact with them, "Did you wash/sanitize your hands?" Compliance with the program was measured through soap/sanitizer usage per resident-the day before, during, and after the intervention. As a result of this intervention, usage increased from 5 HH per patient-day during the preintervention to 9.7 HH per resident-day during the intervention (P < .001), 6.7 HH per resident-day after intervention (6 weeks) (P < .001), and 7.0 HH per resident-day at 3 months (P < .001). This study indicated that patient education increased HH compliance in an inpatient rehabilitation unit by 94% during the 6-week intervention, 34% during the 6-week postintervention, and 40% at 3-month follow-up.3
An observational study by Japanese researchers wanted to measure compliance to a unit-based "rule" that HH was mandatory prior to entering the intensive care unit (ICU). The tool for the observations was a ceiling-mounted video camera connected to a time-lapse videocassette recorder to document each person's actions when he/she entered the ICU during a 7-day period. Hand hygiene compliance was assessed for 3 different categories: ICU personnel, non-ICU personnel, and patient visitors. In 1030 entries to the ICU, HH compliance results were as follows: ICU personnel, 71%; non-ICU, 74%; and patient visitors, 94%. Hand-washing compliance by patient visitors was significantly higher than hospital personnel (P < .001).4
Globally, millions of patients annually succumb to HCAIs. Most HCAIs are preventable through good HH. The WHO guidelines on HH in healthcare support HH promotion and improvement in healthcare facilities worldwide.5 Hand hygiene is the single most important intervention for reducing HCAIs and preventing the spread of antimicrobial resistance.
Richard "Sal" Salcido, MD
References