Analysis: International Hand Hygiene Day shows the fundamental importance of hand hygiene in preventing the spread of drug-resistant germs like MRSA

By Liz Kingston, Colum Dunne, Barbara Slevin and Nuala O’Connell, University of Limerick

Outbreaks of healthcare-associated infection caused by drug-resistant germs or so called "superbugs" like CPE and MRSA are a reminder that we are living in a challenging era of global antimicrobial resistance. Now more than ever, vigilant and proactive infection prevention and control practices including hand hygiene are essential in delivering safe and effective patient health care.

Every year, the World Health Organisation (WHO) celebrates International Hand Hygiene Day on May 5th in order to bring sharp focus on the fundamental importance of hand hygiene in preventing the spread of infection globally. The focus for the hand hygiene campaign this year is on preventing sepsis in healthcare, which is estimated to affect approximately 30 million patients worldwide, every year.

Hand hygiene is recognised globally as the most effective measure a healthcare worker can take to prevent the spread of healthcare-associated infections, which are a risk factor for developing sepsis. Hand hygiene is equally important among patients, their families and visitors. Healthcare-associated infections lead to prolonged hospital stay, increased morbidity and mortality and increased financial burden for patients, healthcare organisations and the exchequer. According to the WHO, hundreds of millions of patients are affected by these infections worldwide each year.

The correct technique is a six-step procedure that should take about one minute when hand washing and 30 seconds when hand rubbing with an alcohol-based product

Latest figures from Ireland show that one in every twenty patients (5.2 percent) admitted to hospitals may develop an infection associated with the healthcare they receive. A review of the research evidence recently reported that observed hand hygiene compliance internationally sits at around just 34 percent, even though hand hygiene is simple, cost-effective and highly efficacious in controlling the spread of infection.

How to properly wash your hands

Hand hygiene pays special attention to meticulously washing all surfaces of the hands with both soap and water or hand rubbing all surfaces with an alcohol-based hand rub solution, usually in the form of gels, liquids and foams. The correct technique is a six-step procedure that should take about one minute when hand washing and about 30 seconds when hand rubbing with an alcohol-based product.

In healthcare settings, hand washing with soap and water is recommended when hands are visibly soiled or for certain microorganisms. However, hand rubbing with an alcohol-based product is more effective in killing microorganisms, more convenient, takes less time and causes less skin damage than hand washing.  It is recommended for most routine hand hygiene indications in most clinical settings (with some exceptions).

Caption

According to the WHO, there are five recommended opportunities when hand hygiene should be performed in any given day where healthcare is delivered. They are simplified into 5 moments to encourage staff to perform hand hygiene at the appropriate times: (1) before touching a patient, (2) before clean or aseptic procedures, (3) after body fluid exposure risk, (4) after touching a patient and (5) after touching patient surroundings.

How compliant are Irish healthcare workers with hand hygiene?

Given that Ireland like other countries is experiencing considerable healthcare-associated infection challenges, it is important that hand hygiene compliance is audited and monitored. National and regional reporting of hand hygiene audits and direct observation monitoring is useful in this regard in providing observed compliance rates.

However, one disadvantage of this type of measurement  is that healthcare workers very often know their performance is being monitored and this can lead to temporary improvements in practices while auditors are present (the Hawthorne affect), only for practice to return to normal when the auditors are gone. National key performance indicators for hand hygiene are measured biannually with target compliance set at 90 percent.

Performing the skill of hand hygiene correctly is a learned behaviour and one that requires sustained behavioural commitment to compliance

Building on earlier work, an independent body of research carried out at the University of Limerick provides further compliance evidence. The research examines attitudes towards and practices of hand hygiene among healthcare workers in the mid-west region. It was carried out by survey, giving respondents a confidential and anonymous opportunity to report on their attitudes and practices and allowed for comparisons over a 10 year period to be drawn.

Attitude influences how humans behave and performing the skill of hand hygiene correctly is a learned behaviour and one that requires sustained behavioural commitment to compliance. Attitudes towards hand hygiene were predominantly positive among those surveyed, which included nurses, doctors, nursing students and medical students, with a minority expressing negative attitudes. Respondents reported good knowledge of national and international hand hygiene standards and guidelines and all had received hand hygiene education and training.

It is reported in medical literature that doctors perform hand hygiene poorly and that nurses are generally more compliant. However, this research shows that hand hygiene practice among doctors in the mid-west has greatly improved in the last ten years, with 86 percent of doctors reporting compliance with hand hygiene before touching a patient, compared to 58 percent in 2007. Compliance reported among nurses was virtually unchanged at 96 percent, compared to 95 percent in 2007. Among healthcare students, the research reports very high compliance after body fluid exposure risk (95 percent) and significantly lower compliance (60 percent) after touching patient surroundings, a result mirrored in international research.

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From RTÉ Radio One's Marian Finucane show, immunologist Christine Loscher from DCU discusses the importance of hand hygiene

While the reported improvements in practice among doctors are very welcome, a reluctance was found among healthcare workers in general to adopt the practice of routinely hand rubbing with an alcohol-based solution, despite the recommendation from the WHO. Just 42 percent of nurses and 39 percent of doctors reported to using alcohol-based hand rubs for hand hygiene almost always as recommended. This suggests a reluctance to change from old patterns of learned behaviour, where hand washing with soap and water was the routine approach.

What are the motivators and barriers to hand hygiene?

This research shows that qualified healthcare professionals are highly motivated by altruistic values, with 48 percent influenced to use alcohol-based hand rub solutions by the "prevention of cross infection", a further 10 percent by "patient outcomes" and 9 percent by "infection control policy". Interestingly, "personal protection" features more prominently among healthcare students (17.5 percent) than healthcare professionals (six percent), suggesting that many nursing and medical students are motivated by self-protection at this early stage in their careers.  

Skin sensitivity and skin damage were identified as barriers to the use of alcohol-based products among almost 30 percent of healthcare workers

The research also identified potential reasons or barriers to why some healthcare professionals may adopt a somewhat laissez-faire approach to hand hygiene. Skin sensitivity and skin damage were identified as barriers to the use of alcohol-based products among almost 30 percent of healthcare workers. This was despite recommendations and concerted efforts by the infection prevention and control team in the mid-west region. 

Given the high levels of direct contact between patients and healthcare workers, there is a high hand hygiene burden for healthcare workers, with estimates suggesting requirements of up to fifteen times per hour, yet just 10 percent of respondents reported "lack of time" as a barrier. Unexpectedly, 24 percent of doctors and seven percent of nurses reported that hand rub was not readily available in clinical settings, despite resolute efforts to ensure availability. Issues around user acceptability and perceptions were also reported - for example, 25 percent of nurses and 30 percent of doctors reported hands do not feel clean after use, while 20 percent of nurses and 39 percent of doctors reported they were unpleasant to use.

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From RTÉ Radio One's Morning Ireland, Professor David Coleman from Trinity College discusses research to detect and prevent the spread of MRSA in Irish hospitals

WHO International Hand Hygiene Day provides an opportunity to campaign to remind healthcare workers globally and locally of the importance of improved hand hygiene practices. Meaningful engagement with healthcare workers on their important role in improving patient outcomes through sustained behavioural change and vigilant approaches to performance monitoring, education, training, and creating an institutional patient safety climate are essential to its impact.

Nurses and doctors have ethical and professional responsibilities as outlined by their regulatory authorities to deliver competent and safe patient care and poor hand hygiene practices breech those responsibilities. Moreover, patients have a right to safe and effective healthcare, delivered by trusted professionals. The National Healthcare Charter seeks to reassure patients about processes in place to ensure safe healthcare delivery specifically addresses the prevention of healthcare associated infections and the importance of hand hygiene in this endeavour.

Dr Liz Kingston is a lecturer and Senior Clinical Skills Labs Co-ordinator at Department of Nursing & Midwifery at University of LimerickProfessor Colum Dunne is Director and Chair of Executive Management Committee and Director of Research at the Graduate Entry Medical School at University of LimerickBarbara Slevin is Group ADON Infection Control at University of Limerick HospitalsDr Nuala O’Connell is a consultant microbiologist & infection prevention and control doctor at the MidWest Regional Hospital, Limerick and an adjunct clinical lecturer at University of Limerick.


The views expressed here are those of the author and do not represent or reflect the views of RTÉ