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Mon 21 May 2007 05:17 PM

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Keeping it clean

Hand hygiene is key to infection control.

In 2002, the release of the United States Centres for Disease Control's new guidelines for handwashing, including how and when workers should wash their hands, followed a study by infection control experts at the University of Geneva Hospitals that found a 50% drop-off in patient infections after modest increases in handwashing by staff members.

Hospital workers have known since the mid- to late-19th century that it's important for them to wash their hands. As early as 1843, Dr. Oliver Wendell Holmes advocated handwashing to prevent childbed fever. Holmes believed that the fever was an infectious disease passed to pregnant women by the hands of doctors. He recommended that a physician finding two cases of the disease in his practice within a short time should remove himself from obstetrical duty for a month. Holmes's ideas were greeted with disdain by many physicians of his time.

In 1847, Dr. Ignac Semmelweis, an assistant in the maternity wards of a Vienna hospital, became somewhat obsessed with the notion of handwashing. Semmelweis observed that the mortality rate in a delivery room staffed by medical students was up to three times higher than in a second delivery room staffed by midwives. He found that the students were coming straight from their lessons in the autopsy room to the delivery room-bringing with them all kinds of harmful germs. He ordered doctors and medical students to wash their hands with a chlorinated solution before examining women in labour.

The mortality rate in his maternity wards eventually dropped to less than one percent. Nevertheless, the zeal with which Semmelweis advocated hand-washing led to his being hounded out of the job. His then-radical notion caught on a few decades later.

Despite its rocky beginnings, handwashing has become part of the fabric of medical care-and in the developed world part of the culture. Handwashing and other hygienic practices are taught at every level of school, advocated in the workplace, and emphasised during medical training. According to the CDC, "Handwashing is the single most important means of preventing the spread of infection."

But getting doctors and nurses to become obsessive hand washers is proving difficult. Experts estimate that health practitioners comply with recommended hand hygiene procedures less than 50% of the time - contributing to some dire consequences. Nearly two million hospitalised patients in the US develop infections each year, and the most common transmitters of health-care-associated pathogens are the contaminated hands of healthcare workers. 80,000 patients die from these infections each year. While we are all potentially at risk of contracting hand-transmitted illnesses, one-third of our population is especially vulnerable, including pregnant women, children, the elderly, and those with weakened immune systems.

For most healthcare workers, it's a question of competing priorities. Quick-drying hand gels that kill bacteria without need of soap and water are now standard fare in 95% of U.S. hospitals. But still, at 30 seconds per hand wash, busy hospital workers who constantly jump from patient to patient could spend 10 minutes per hour washing their hands, leaving them less time to do other important tasks, like examining patients and double-checking drug doses.

Sterilisation has long been the norm in operating rooms, but that thinking doesn't necessarily carry over to other areas of the hospital, where seemingly innocuous tasks such as picking up a patient's chart, touching your necktie, or typing on a computer keyboard can easily spread germs. In many hospitals, infection control specialist find themselves spending a lot of time on the unpleasant task of policing their fellow staff members.

Why is compliance with such a basic task so poor? There are a number of factors, say the experts. Sometimes it's a lack of time or opportunity, such as during an extreme emergency. Other times it may be due to poor access to handwashing facilities, or avoidance due to skin irritations caused by frequent use of soap and water. Most often, though, it is the result of insufficient knowledge among personnel about the importance of good hand hygiene, lack of understanding of correct hand hygiene indications and technique, and/or lack of institutional commitment to promoting and supporting good hand hygiene. It doesn't help that existing guidelines for hand hygiene are more complicated than one might think. The CDC's guidelines are exhaustive and complex.

For example, the guidelines urge healthcare workers to regard all surfaces in the vicinity of the patient as potentially contaminated and to practice hand hygiene accordingly. But does that mean they should wash after they touch any potentially contaminated objects and surfaces in a patient's room? There are rules about washing in the midst of a single encounter with a patient if, for instance, the clinician touches a contaminated or potentially contaminated part of the patient's body and then moves his or her hands to a "clean" part of the body (such as an intravenous catheter site).

Other rules spell out when it's necessary to wear sterile gloves (when inserting a catheter, for example, and even then, hands should be washed before donning gloves), when to use antimicrobial soap and water (when hands are visibly soiled or have been exposed to bodily fluids) and when to use an alcohol-based gel or rub (for routine decontamination of hands after most patient contact, but not after contact with a patient who has antibiotic-associated colitis due to Clostridium difficile).

You can review the CDC's handwashing guidelines by visiting the CDC website here:

. Here are some basics to help guide individual clinicians as well as those who are charged with setting and maintaining solid infection control policies.

When should healthcare workers wash their hands?

• Before and after each contact with patients, body fluids, and contaminated or soiled materials

• Between dirty and clean procedures on the same patient, after removing gloves

• Before and after performing invasive procedures

• After using the washroom or restroom

• Whenever hands are visibly soiled

What should clinical staff use to clean their hands?

Infection control experts recommend that healthcare workers should use liquid soap from pump dispensers. Ideally, the dispenser should be disposable; refillable dispensers should be carefully rinsed and washed before refilling to avoid contamination.

Regarding the kind of soap used, experts advise that antibacterial soaps are not necessary for routine use, while warning against soaps containing alcohol (which can dry and damage skin) and bar soaps (which frequently are wet and thus easily contaminated with potential pathogens). Use of sinks is preferred to waterless hand cleansers, especially if the hands are soiled.

Paper towels are preferred for hand drying and always should be available and reached easily by the healthcare professional. Hand lotions should be available in pump-type containers that are either completely replaced or cleaned at regular intervals. Hand lotions should not be petroleum-based as this may cause deterioration of latex material and thus reduce the effectiveness of gloves.

The method of hand-washing

The method of hand-washing depends on the task to be performed. Routine hand-washing should be done by thoroughly covering the hands with soap and vigorously rubbing the hands under running water for at least 10 seconds. Before performing invasive procedures, healthcare workers should wash with antimicrobial soaps, such as chlorhexidine or povidone-iodine. They should also clean their nails with disposable manicure sticks.

Policies and procedures

It is a good idea to provide and review information on infection control in general and hand-washing in particular at the time of orientation. Furthermore, regularly scheduled educational sessions for all staff are important to ensure that the level of hand-washing and infection control awareness remains high.

Policies for infection control should be written, readily available, and enforced. These and other policies related to patient safety should be part of the clinical culture.

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