It’s Simply in Our Hands

Estimates indicate that a large number of patients suffer from healthcare-associated infections (HCAI) each year worldwide. HCAI are infections occurring in a patient during the process of care in a healthcare facility. This includes infections acquired in the hospital but appearing after discharge and also occupational infections among staff of the facility. Although the risk of acquiring these infections exists worldwide, the risk and impact are likely to be higher in resource-constrained settings where compliance with standard recommendations for infection prevention and control is generally not optimal. The capacity of existing systems to respond to the increased demand associated with HCAI, such as length of stay, cost, effective antimicrobial therapy and advanced technology is also limited in such settings.

Hospital acquired infections, many of which are transmitted from patient to patient by poorly sanitized hands of healthcare workers, exert a significant toll in human and economic terms. The most common HCAI are urinary tract, surgical site, lower respiratory tract and bloodstream infections. Yet good hand hygiene, the simple task of cleaning hands at the right times and in the right way, can save lives. World Health Organization (WHO) has developed evidence-based WHO Guidelines on Hand Hygiene in Healthcare to support healthcare facilities to improve hand hygiene and thus reduce HCAI.

A global response to the problem

A large proportion of HCAI is preventable. The first goal towards patient safety should be “Do no harm” and reduce the adverse health and social consequences of unsafe healthcare. The World Health Organization (WHO) contributes to this effort through the Patient Safety Programme with its First Global Patient Safety Challenge “Clean Care is Safer Care” (CCiSC), launched in 2005 and dedicated to the prevention of HCAI.

One of the important recommendations for reducing HCAI is compliance with hand hygiene practices. Although maintaining hand hygiene is a simple act that should be routine behaviour among healthcare workers (HCWs), data from studies worldwide show that compliance is universally low. To achieve sustained improvement in hand hygiene, determined efforts are required at the point of care. For this reason, the core focus of CCiSC is on improving hand hygiene in healthcare and one of its main outputs, the WHO Guidelines on Hand Hygiene in Healthcare, (available at: http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf) which provides detailed recommendations and tools (available at: http://www.who.int/gpsc/5may/tools/en/index.html) to facilitate change.

In 2009, WHO Patient Safety launched an extension to this programme “SAVE LIVES: Clean Your Hands”, an initiative that aims to ensure an ongoing global, regional, national and local focus on hand hygiene in healthcare. In particular, “SAVE LIVES: Clean Your Hands” reinforces the “My 5 Moments for Hand Hygiene” approach as key to protect the patient, the healthcare worker and the healthcare environment against the spread of pathogens and thus reduce HCAI. This approach encourages healthcare workers to clean their hands

1. Before touching a patient,
2. Before clean/aseptic procedures,
3. After body fluid exposure/risk,
4. After touching a patient and
5. After touching patient surroundings.

The Barriers

Hand hygiene has always been considered one of the cornerstones of infection control but adherence to recommendations for hand-hygiene practices remain extremely low in most healthcare settings. Compliance with hand washing in hospital environments is generally less than 50%. Large number of barriers to appropriate hand hygiene have been reported. Careful epidemiological investigations have clearly identified some of the key parameters involved and have proposed corrective measures. The leading factor for non-compliance is time constraint. Other reasons reported by healthcare workers for the lack of adherence to hand hygiene recommendations include: skin irritation by hand hygiene agents, inaccessibility of hand hygiene supplies, interference with healthcare workers-patient relationship, patient needs perceived as a priority, wearing of gloves, forgetfulness, the lack of knowledge of guidelines, insufficient time for hand hygiene, high workload and understaffing, and the lack of scientific information showing a definitive impact of improved hand hygiene on hospital-acquired infection rates. But, above all, its lack of awareness about the importance of hand hygiene which appears to be a mundane procedure to most of healthcare workers, including doctors.

Etiquettes

Two major types of microorganisms may be found on the skin: organisms that reside on it (resident flora) and transient or contaminant flora. Unless introduced into the body by trauma or invasive devices, the pathogenic potential of the resident flora (coagulase-negative staphylococci, Corynebacterium species, Micrococcus species) is considered low. In contrast, transient flora (typically Escherichia coli, Pseudomonas aeruginosa) cause most nosocomial infections resulting from cross-transmission but they are easily removed by hand washing.

Hand hygiene can be achieved through either hand washing or hand disinfection. Hand washing refers to the action of washing hands with an unmediated detergent and water, or water alone, to remove dirt and loose transient flora to prevent cross-transmission

Hygienic hand washing refers to the same procedure with the addition of an antiseptic agent. Hand disinfection refers to any action in which an antiseptic solution, either medicated soap or alcohol, is used to clean hands.

Some experts refer to the use of detergent-based antiseptics or alcohol as “de-germing”. Hand rub consists of rubbing hands with a small quantity of a highly effective and fast-acting antiseptic agent. Because alcohols have excellent activity and the most rapid bactericidal action of all antiseptics, they are the preferred agents for hygienic hand rubs. Other antiseptics include iodophores, chlorhexidine gluconate, triclosan, phenol derivatives, and quaternary ammonium compounds. The objective of hand hygiene is to decrease hand colonization with transient flora. To have a high impact, the ideal technique should be quick to perform, reduce hand contamination to the lowest possible level, and be free from deleterious side effects like dryness, cracks and irritant dermatitis.

Compliance

Easy, immediate access to hand-hygiene facilities and agents and rapid antimicrobial action are key elements to improve compliance. Bedside hand rubbing requires only 20 seconds, thus bypassing the time constraint factor. Promoting alcohol-based hand rubs is recommended because they require less time to use, are more effective, and are less irritating to skin than traditional hand washing. Importantly, hand cleansing is required regardless of whether gloves are used or changed. Failure to remove gloves after patient contact or between dirty and clean-body-site care on the same patient has to be regarded as non-compliance.

Furthermore, it is not appropriate to wash and reuse gloves between patient contact and hand hygiene is recommended after glove removal.

Several reports have stressed the risk that staff may move from patient to patient without glove change, resulting in the subsequent cross-transmission of nosocomial pathogens. Recommendations are:

1. Wear gloves when contact with blood, body fluids, or other potentially infectious materials, mucous membranes, and non-intact skin can be reasonably anticipated;
2. Remove gloves after caring for a patient; Do not wear the same gloves for the care of more than one patient;
3. Do not wash gloves between patients; and
4. Change gloves during patient care if moving from a contaminated body site to a clean site.

Knowledge about hand hygiene, awareness of personal hand washing practices, types of hand hygiene products and accessibility of supplies have all been recognised as factors that may influence healthcare workers’ adherence to hand hygiene recommendations. Education and training, the most frequently implemented interventions designed to improve adherence, have had limited long-term success. Interventions focused on the organizational level have shown some evidence of improving adherence. Yet “being too busy” is often cited as an explanation for not practicing recommended hand hygiene, even though prevention of patient infections is recognized as the most important reason for adherence. Strategies to improve hand-hygiene compliance must be multifaceted and include staff education and motivation, the use of performance indicators, and hospital management support.

Mainstay of compliance is a continuous ongoing training and education. It has to be mandatory at every level – doctors included. Educational programmes are vital & they need to address issues such as availability and awareness of guidelines for hand hygiene, potential risks of transmission of microorganisms to patients as well as potential risks of staff colonization or infection acquired from the patient, knowledge about indications for hand hygiene during daily patient care, awareness of the very low average compliance with hand-hygiene practices of most health-care workers, and recognition of opportunities for hand hygiene associated with high risk for cross-transmission.

Some of these targets are clearly related to the institution and would require senior management support and commitment to be effective.