The Importance of Healthcare and Hand Washing

Abstract

Introduction

Infection control activities involves hand hygiene which is considered to be an important element of it.. In the rouse of the growing burden of health care associated infections (HCAIs), the increasing extremity of illness and complexity of treatment, superimposed by multi-drug resistant (MDR) pathogen infections, health care practitioners (HCPs) are reversing back to the basics of infection preventions by simple measures like hand hygiene.Hand hygiene alone can significantly reduce the risk of cross-transmission of infection in healthcare facilities (HCFs).this is because enough scientific evidence supports the observation that if properly implemented.

Historical Background

The implication of hand washing in patient care was formulated in the early 19th century6–8. Labarraque6 provided the first evidence that sanitizing hand can extremely reduce the occurence of puerperal fever and maternal mortality. Semmelweis7 worked in the Great hospital in Vienna in the 1840s. The hospital had two maternity clinics in it which provides the facility of admission policy in alternative days. The first clinic was handled by medical students, who moved straight from autopsy rooms to the delivery suite and had an average maternal mortality rate due to puerperal fever of about 10%.

The second clinic, attended by midwives had a maternal mortality of only 2%. The puzzled Semmelweis got a breakthrough in 1847, following the death of colleague JokobKolletschka, who had been accidentally got a cut by a student's scalpel while performing an autopsy. His autopsy showed a pathological condition similar to that of women drying from puerperal fever. Semmelweis concluded that some “unknown cadaverous material” was the reason behind this puerperal fever. He established a policy of washing hands with chlorinted lime for those leaving the autopsy room, following which the rate of maternal mortality dropped 10%, comparable to the second clinic. Thus, he almost conducted a controlled trial, in an era when microbes were yet to be discovered and the germ theory of disease was unexplained. In another critical point of study in the rouse of Staphylococcal epidemics in 1950s, Mortimer et al9 showed that direct contact was the main mode of transmission of S. aureus in nurseries. They also demonstrated that hand washing by patients’ contacts minimize the level of S. aureusacquisition by babies.

In 1975 and 1985, the CDC published guidelines on hand washing practices in hospitals, primarily recommended hand washing with non antimicrobial soaps; washing with antimicrobial soap was advised before and after performing intrusive procedures or during care for high risk patients. When the sinks are not available, alcohol based solutions are preferred for sanitizing hands.. In 1995, the Hospital Infection Control Practices Advisory Committee (HICPAC) recommeded the use of antimicrobial soap or a waterless antiseptic agent for cleaning hands upon leaving the rooms of patients infected with multidrug-resistant pathogens12. In 2002, the CDC published revised guidelines for hand hygiene3. A major change in these guidelines was the recommendation to use alcohol based hand rubs for sanitization of hands between each patient contact (of non-soiling type) and the use of liquid soap and water for cleaning visibly contaminated or soiled hands. A systematic review of handwashing by the Thames Valley University as part of the evaluation of processes and indicators in infection control (EPIC) study, concluded that there was a good evidence that direct patient contact resulted in hand contamination by pathogens. This extraordinary and ancient study also showed the superiority of 70 per cent alcohol/ alcohol based antiseptic hand rub.

With the growing load of HAIs, limited options of effective antimicrobials evidence supporting the role of hand hygiene in minimization of HAIs, the WHO has launched a global hand hygiene campaign. In 2005, it introduced the first Global Patient Safety Challenge “Clean Care is Safer Care (CCiSC)”, as part of its world alliance for patient safety. In 2006, advanced draft guidelines on 'Hand Hygiene in Health Care' were published and a suite of implementation tools were developed and tested17. The first Global Handwashing Day was observed on October 15, 2008. A WHO Patient Safety 2009 initiative has been established to contribute this progress. This is the next phase of the ‘First Challenge's work on CCiSC′. This initiative has, as of April 2009, seen a total of 3,863 health care facilities registering their commitment, effectively equating to a staff of over 3.6 million people, globally. On May 5, 2009, the WHO highlighted the importance of hand hygiene and launched guidelines and tools on hand hygiene, based on the next phase of patient safety work programme “SAVE LIVES: Clean Your Hands”.

Normal flora of hands

There are two types of microbes colonizing hands: the resident flora, which consists of microorganisms residing under the superficial cells of the stratum corneum and the transient flora, which colonizes the superficial layers of the skin, and is more controllable to removal by routine hand hygiene. Transient microorganisms survive, but do not usually multiply on the skin. They are often acquired by health care workers (HCWs) during direct contact with patients or their nearby polluted environmental surfaces and are the organisms most frequently associated with HCAIs.

Colonization of hands with pathogens and their role in transmission

The hands of HCWs are commonly colonized with pathogens like methicillin resistant S. aureus (MRSA), vancomycin resistant Enterococcus (VRE), MDR-Gram Negative bacteria (GNBs), Candida spp. andClostridiumdifficle, which can survive for as long as 150 h. Approximately 10 skin epithelial cells containing viable microorganisms are shed daily from the normal skin, which can contaminate the gowns, bed linen, bedside furniture, and other objects in the patient's immediate environment. Hand conveyance of resistant pathogens has repeatedly been shown to be associated with nosocomial infections. The highest rates of hand contamination are reported from critical care areas, which also report most cases of cross-transmission. The hands may become contaminated by merely touching the patent's intact skin or insensate objects in patients’ rooms or during the “clean” procedures like recording blood pressure.

Importance of hand hygiene

While considering the hand hygiene, it is the most simplest and cost effective way toreducing the prevalence of HAIs and the spread of antimicrobial resistance. Several studies have demonstrated that handwashing virtually eliminates the conveyance of MRSA which invariably occurs on the hands of HCPs working in ICUs. An increase in handwashing compliance has been found to be accompanied by a fall in MRSA rates. The hand hygiene liason group identified nine controlled studies, all of which showed significant reductions in infection related outcomes, even in settings with a high infection rates in critically ill patients. Transmission of Health-care-associated Klebsiella sp. has also been documented to reduce with improvement in hand hygiene. The evidence suggests that adherence to hand hygiene practices has significantly reduced the rates of accession of pathogens on hands and has ultimately reduced the rates of HAIs in a hospital.

Indications for hand hygiene during patient care

Wash hands with soap and water when (i) visibly dirty or contaminated with proteinaceous material, blood, or other body fluids and if exposure to Bacillus anthracis is suspected or proven (since the physical action of washing and rinsing hands in such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores); (ii) After using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water; and (iii) before and after having food.

In all other clinical situations described below, when hands are not visibly soiled, an alcohol-based hand rub should be used routinely for sanitizing hands. (i) Before having direct contact with patients. (ii) Before throwing sterile gloves when inserting a central intravascular catheter. (iii) Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure. (iv) After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient). (v) After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. (vi) After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. (vii) After removing gloves. (viii) If moving from a contaminated body site to a clean body site during patient care.

The WHO “SAVE LIVES: Clean Your Hands” programme reinforces the “My 5 Moments for Hand Hygiene” approach as key to protect the patients, HCWs and the health-care environment against the spread of pathogens and thus reduce HAIs. This approach encourages HCWs to clean their hands: before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient and after touching patient surroundings.

Other Precautions in Relation to Hand Sanitation

Avoid unnecessary touching of surfaces in close proximity to the patient. In 2002, the CDC/HICPAC recommended that artificial fingernails and extenders not to be worn by HCPs who have contact with high-risk patients, due to their association with outbreaks of Gram-negative bacillary and candidal infections. Although rings harbour a high count of pathogens, they have not been found to be associated with transmission of infections.

Method of Hand Washing

For hand washing, remove the worn onaments and rinse hands under running water (preferably warm). Lather with soap and using friction, cover all surfaces of hands and fingers. Wash thoroughly under running water. Turn off faucet with wrist/elbow. Dry hands with a single use towel or by using forced air drying. To avoid cracking, pat skin gently rather than rubbing. If disposable towels are used, throw in trash immediately. Skin excoriation may lead to bacteria colonizing the skin and the possible spread of blood borne viruses as well as other microorganisms. Sore hands may also lead to decreased compliance with hand washing protocols. If using antiseptic rub, take an adequate amount and rub on all surfaces for the recommended time. Let the antiseptic dry on its own.

Selecting Hand Hygiene Products for Health Set-Ups

The major determinants for product selection are antimicrobial profile, user acceptance, and cost. Post-contamination hand hygiene products must have at least bactericidal, fungicidal (yeasts), and virucidal (coated viruses) activity. Since hands of HCWs are frequently contaminated with blood during routine patient care, activity against coated viruses should be included in the minimum spectrum of activity of an agent for hand hygiene. Additional activity against fungi (including molds), mycobacteria, and bacterial spores may be relevant in high risk wards or during outbreaks. Pre-operative hand hygiene should be at least bactericidal and fungicidal (yeasts), since the hands of most HCWs carry yeasts and surgical- site infections have also been associated with hand carriage of yeasts during an outbreak.

Hospital administrators should also take into account the acceptability of product (smell, feel, skin irritation) by the users and its allergenic potential. When comparing the cost of hand hygiene products, it has been found that the excess hospital cost associated with only 4-5 HAIs of average severity may equal the entire annual budget for hand hygiene products used for in-patient care areas. One of the key elements in improving hand hygiene practice is the use of an alcohol based hand rub instead of washing with soap and water. An alcohol-based hand rub requires less time, is microbiologically more effective and is less irritating to skin than traditional hand washing with soap and water. In the ICUs, switching to alcohol hand disinfection would decrease the time necessary for hand hygiene from 1.3 h (or 17% of total nursing time) to 0.3 h (or 4% of total nursing time).

Reasons for Poor Hand Hygiene Practices

In most health care institutions, adherence to recommended hand-washing practices remains unacceptably low, rarely exceeding 40 per cent of situations in which hand hygiene is indicated. Hand hygiene reflects attitudes, behaviours and beliefs. Some of the observed/self reported factors found to be affecting hand hygiene behaviours are enlisted in.

Methods Used to Improve Hand Hygiene Compliance

Multimodal strategies have been shown to be more successful in improving rates of adherence with hand hygiene in HCWs than single involvement. Targeted, multi-faceted approaches focusing on system change, administrative support, motivation, availability of alcohol-based hand rubs, training and intensive education of HCWs and reminders in the workplace have been recommended for improvement in hand hygiene. Recent studies support the fact that interactive educational programmes combined with free availability of hand disinfectants significantly increased the hand hygiene compliance. A single lecture on basic hand hygiene protocols had a significant and sustained effect in enhancing hand hygiene compliance in a Swedish hospital.

The four member States of the European Union, which implemented National Hand Hygiene Campaigns found the following strategies to be extremely useful in their countries: Governmental support, the use of indicators for hand hygiene benchmarking, developing national surveillance systems for auditing alcohol based hand rub consumption and auditing hand hygiene compliance. Trampuz et al recommended simple training sessions for HCWs to be held in each ward to introduce the advantage of alcohol hand rubs over hand washing.

Other factors like positive role modeling (hand hygiene behaviour of senior practitioners) and the use of performance indicators also remarkably improve adherence to hand hygiene. There should be adequate supply of hand hygiene products, lotions and creams, disposable towels and facilities for hand washing, where necessary. Alcohol hand rubs should be available at the point of care in sufficient quantities. It needs to be emphasized that wearing gloves does not replace the need for hand hygiene and that sanitization may occur during glove removal. Studies by Pitetshowed a remarkable and long lasting improvement in hand hygiene compliance using a multimodal strategy, which has been adopted by the first Global Patient Safety Challenge of WHO to develop hand hygiene strategies. The availability of individual, pocket carried bottles also increased compliance.

Apart from this, all hospitals should have a dynamic infection control team, strong surveillance system, adequate staff to disseminate evidence-based knowledge in an easily comprehensible way to all cadres of staff. At a more local or regional level, there is a need for institutional frameworks or programmes to deal with HAIs. The Institute for Healthcare Improvement (www.ihi.org) offers elaborate training modules on various aspects of patient care. The guide for implementation of WHO's CCiSC and a range of tools to facilitate hand hygiene is available.

Research and Education

More research into behavioural determinants is neededto develop successful interventions, in particular, how these determinants can be applied to improve hand hygiene. Process indicators are vital and an understanding of why some interventions succeed and others fail is needed. Since hand hygiene is more of a behavioural practice, the first step towards the development of interventions should be to identify the prevalence of risk behaviours (i.e. non compliance) and the difference in risk behaviours. Since the reasons for non-compliance vary among countries, large scale systematic studies are needed to identify the reasons thereof and plan remedial strategies. An expert panel has recommended that measuring hand hygiene compliance is essential to understand the current situation, facilitate change and to measure the impact of interventions. This can be done by direct observation, automated electronic monitoring, product consumption and self reporting by HCW54.

The important aspect of role models for students, whose adherence is strongly influenced by their mentor's attitude at bed side should be exploited in moulding the behaviour of young medical students. A few lectures in the undergraduate curriculum may prime the medical students to this basic necessity. The Hand Hygiene Liason Group strongly advocates teaching of elementary hygiene practices at medical schools. In an elaborate study focusing on MBBS students, it was noted that assessing the knowledge, attitude and practices of final year MBBS students and providing a positive role modeling at undergraduate level is a good initiative.

Indian Scenario

In India, various factors are there to govern the quality of healthcare, the principal amongst these being whether the health care organization is government or private-sector run. There is also an economic and regional disproportion throughout the country. About 75% of health infrastructure, medical manpower and other health resources are concentrated in urban areas, where 27% of the population lives. There is a lack of availability of clean water for drinking and washing. Like in other developing countries, the priority given to prevention and control of HCAI is minimal. This is primarily due to lack of infrastructure, trained manpower, surveillance systems, poor sanitation, overcrowding and understaffing of hospitals, unfavourable social background of population, lack of legislations mandating accreditation of hospitals and a general attitude of non-compliance amongst health care providers towards even basic procedures of infection control.

In India, although hand hygiene is imbibed as a custom and promoted at school and community levels to reduce the burden of diarrhoea, there is a paucity of information on activities to promote hand hygiene in HCFs. Sporadic reports document the role of hands in spreading infection and isolated efforts at improving hand hygiene across the country. The practice of compulsory training on standard precautions, safe hospital practices and infection control for all postgraduates upon course-induction, as is being done in a few Delhi medical colleges seems very promising for our country. Such an exercise may be made mandatory across all medical and nursing colleges of India, especially since the “patient safety” is increasingly being prioritized by the Government of India and the country being one of the 120 signatories pledging support to the WHO launched world alliance.

Challenges Ahead

Although evidence based guidelines are increasingly being implemented in the developed countries, the developing countries still lack basic health care facilities, surveillance networks and resources to curtail HAIs. Lack of hand washing facilities (e.g., sinks, running water and sewage systems) are major deterrents for implementation of hand hygiene. The use of WHO recommended alcohol based hand rubs is a practical solution to overcome these constraints, because these can be distributed individually to staff for pocket carriage and placed at the point of care. The major advantage is that its use is well applicable to situations typical of developing countries, such as two patients sharing the same bed, or patient's relatives being requested to help in care provision. Several hospitals are now reporting increased compliance after implementation of CCiSC. Several countries have also initiated nationally co-ordinated activities (http://www.who.int/gpsc/national-campaigns/en/) to promote hand hygiene. However, global Healthcare Infection Prevention programmes can only be successful, if these populous developing nations are able to control the menace by formulation of national or local policies and strictly implementing the guidelines.

Conclusion

People should understand the importance of healthcare and Hand washing should become an educational priority as the first step toward it. Educational interventions for medical students should provide clear evidence that HCWs hands become grossly contaminated with pathogens upon patient contact and that alcohol hand rubs are the easiest and most effective means of decontaminating hands and thereby reducing the rates of HAIs. Increasing the emphasis on infection control, giving the charge of infection control to senior organizational members, changing the paradigm of surveillance to continuous monitoring and effective data feedback are some of the important measures which need to be initiated in Indian hospitals. One of the reasons microbes have survived in nature is probably their simplicity: a simple genomic framework with genetic encryptation of basic survival strategies. To tackle these microbes, human beings will have to follow basic and simple protocols of infection prevention. The health care practitioners in our country need to brace themselves to inculcate the simple, basic and effective practice of hand hygiene in their daily patient care activities and serve as a role model for future generations of doctors, nurses and paramedical personnels.