Preventing Hospital Acquired Infections Takes More Than Hand Hygiene

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Is hand hygiene enough?
The simple answer is no. Despite improvements, “gaps” still remain.

Executive Summary:
For over a decade, researchers and healthcare professionals have been fighting an uphill battle on how to protect patients, staff and the general public against healthcare acquired infections (HAIs). The impact goes beyond the financial cost of having to treat patients who are acquiring infections while staying in healthcare facilities.

One of the critical lines of defense against HAIs … Washing your hands. However, research shows hand hygiene isn’t 100%, especially when it comes to healthcare worker compliance. 

Research has revealed that surfaces in hospitals and other healthcare facilities – specifically touch points, i.e., privacy curtains, bedrails, door handles, sinks, countertops, etc. – are points of contamination. Even with protocol-driven housekeeping and laundering, re-contamination occurs.

According to the Centers of Disease Control (CDC), 1.7 million patients are infected each year during hospitalizations in the U.S. Sadly, more than 99,000 people die each year. And the financial burden runs as high as $40 billion a year. For a further glimpse into HAI’s, see www.cdc.gov/hai.
Acquiring an infection in a hospital runs to one of the key precepts, “Do No Harm”. Healthcare facilities have been looking for ways to identify and employ the best methods to reduce HAIs. One of the first goes back to something your mom may have taught you.

First Line of Defense: Wash your hands
One of the oldest methods to prevent the spread of disease is simply to wash your hands. During cold and flu season, public health officials turn to the media, and in addition to urging people to cover their mouth and nose when they sneeze, they also remind people to wash their hands more frequently.
It is simple then for healthcare workers (HCW) to turn to this method in the fight to reduce the re-occurrence of HAIs.

It has been a decade since the Centers for Disease Control published its “Guideline for Hand Hygiene in Health-Care Settings (2002), but the question remains, “Does hand washing and sanitizing actually ‘work’?”
How you define “work.”

The benefit of hand washing or using sanitizers in reducing HAIs is predicated on two key factors:

1. Did the HCW actually wash or sanitize their hands between patients?
2. Did their hands become clean and sterile by doing so?

Educating HCW’s on the risks of poor hand hygiene in healthcare setting can help begin changing behaviors and habits. Programs designed through the World Health Organization (WHO) and the Centers for Disease Control (CDC) have raised awareness of HAIs in particular. But, after educating and writing the new protocols and procedures, then begins the hard work of compliance measurement.

Several methods have been employed to drive greater hand-washing compliance, including measuring the amount of soap and hand sanitizer used, but that’s a very poor measure – just because more soap or sanitizer is used doesn’t mean a healthcare worker’s hands are “clean and sanitized.”

Hospitals and healthcare facilities employ consultants to monitor compliance. The downside is the expense of employing the consultants and if a healthcare worker is being observed, they exhibit greater compliance (i.e., they wash their hands to be seen as either being a “good” employee, or they do it to avoid a black mark for non-compliance).

Take away the consultant the outcome generally results in the healthcare worker being less diligent in hand washing.  How the hand washing is actually done that reveals another “gap” in the program. An article written in Infection Control Today (Feb. 2012), stated:

Current practices and attention to infection control are focused on sanitizing the hands of healthcare workers as they move from one patient to the next. Hand washing and alcohol sanitizers to achieve reduction of pathogen contamination of bare hands are the dominate means in use. Nothing is done about exam gloves other than sometime putting on a new pair after washing. Alcohol sanitizers are faster and more convenient but is ineffective on all endospores; C. diff being an example, and on many viruses. Hand washing can be more effective, but is not practical given the time (20 seconds) and the requirement to sanitize as well as the effects of skin irritation, and as a result the typical rate of compliance is estimated at about 40% or slightly higher.

So the question remains, does all this hand-washing and sanitizing truly reduce the rate of HAIs?  With the education and public awareness of programs through the World Health Organization (WHO) and the Centers for Disease Control (CDC), it does show that HAI’s in healthcare facilities given the proper education and training protocols can reduce the spread of HAI’s in healthcare facilities.

In Summary:
Most methods used such as hand washing and the use of alcohol sanitizers to clean hands between patients, education, training and monitoring programs will help boost compliance. Keep in mind, the “gap” that remains is it seems there just isn’t enough time between patients to allow healthcare workers to “scrub up” in order to achieve the sterile state needed to lower or even eliminate cross contamination.

What about everybody else?
One factor that becomes glaringly apparent in almost all of the HAIs and hand-washing research is the fact that it deals with only those workers who interact directly with patients. Common sense says this should be and is rightly so.

But, again, there are other “gaps” in the defense against HAIs:

1. What about other non-medical staff that move around in the patient and public spaces?
2. What about visitors who may be walking germ farms?
3. How about the patients themselves?

Focusing on just the patient-hygiene issue, the logic followed goes like this: Healthcare workers should be washing or sanitizing their hands as they move from patient to patient. The thinking is that if one patient is carrying MRSA, for instance, the nurses, respiratory therapists and others treating this patient should wash up before moving to another patient.

Think about this:
Suppose this patient is post-op and wants to simply take a walk … he or she reaches up to push aside the privacy curtain, maybe steadies himself or herself on a sink or countertop, then uses the handrail as he or she makes his or her way down the corridor.

What about the touch points?
A review shows there is risk of contamination for common touch points in healthcare environments. Take the privacy curtain, sink or countertop this patient just touched. The results are not encouraging.

Privacy Curtains Harbor Microbes
Hand contact with privacy curtains transfer some of the worst pathogens for healthcare acquired infections. Healthcare workers can transfer MRSA, VRE and C. Diff from infected patients to the curtain, or vice versa.

Privacy curtains are a key touch point in spreading infection for several reasons. Patients and healthcare workers constantly touch them all the time simply because they surround a patient’s bed. Cleaning or change-outs happen infrequently or at long intervals.  And finally, healthcare workers might not follow hand-washing protocols if they’ve touched a surface or object versus following direct contact with patients. Privacy curtains are frequently contaminated with pathogens, and these organisms can be transferred to the hands.

More Methods and Materials for Research and Development are needed:
Consider the touch point scenarios cited above, it becomes clear there are other potential sources for cross contamination. Just like spotty hand-washing, the cleaning and laundering protocols and actual operations can be hit or miss. This would indicate the need for further research and field testing of other methods, protocols and materials to reduce contamination.

The fight against healthcare-acquired infection does, indeed, start with the professional who cares for the patient, as well as the infection prevention professionals tasked with lowering the rates of infection and cross-contamination. It is a time consuming and intricate task, but much still needs to be researched and proven as to “what works and what doesn’t”.

Krysten Comperchio is the Product Manager for Skin Care and Education at Betco Corporation.