Patient Hand Hygiene: The missing link in preventing Hospital Acquired Infections?

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Abstract:

Hospital acquired infections (HAI’s) are a major threat to patient safety and there is substantial evidence that good hand hygiene reduces the transmission of these diseases. However, most hand hygiene initiatives have focused on the role of the healthcare worker, caregiver, volunteer, etc. The role of the patient is often described in terms of being an advocate in ensuring those charged with their care are practicing good hand hygiene. Patient hand hygiene practices have been largely overlooked in infection prevention within hospitals.

Main Article:

In an interview-based study out of the University of Wisconsin-Madison (May 2014), researchers found that patient hand washing habits practiced at home were better than those practiced after being admitted to the hospital. For example, 85% of respondents report washing their hands after using the washroom at home, compared to only 69.5% in the hospital.  Likewise, 64.7% washed their hands before eating at home, while only 41.4% did so in the hospital.

In a study published in Infection Control and Hospital Epidemiology (November 2014), a research team used a system that attaches transponders to patient bracelets to log their movement and every use of soap and hand sanitizer. Over a period of several months in an acute-care hospital ward, a total of more than 200 patients almost never cleaned their hands before, during or after visiting a patient kitchen/pantry area. The overall hand hygiene rate after using the restroom was under 35%, as was the rate of hand cleaning before having breakfast.

overall hand hygiene rate after using the restroom was under 35%

The ramifications of dirty patient hands could be enormous. Leading thinkers are beginning to point to patient hand hygiene as a critical weak link in controlling those HAI’s that spread via the fecal-oral route. These pathogens include norovirus, Clostridium difficile, Vancomycin-resistant Enterococci (VRE), and the worrisome carbapenem-resistant Enterobacteriaceae (CRE).

Virtually all the focus on hand hygiene in hospitals has lined up behind the World Health Organization’s (WHO) goal of getting staff to wash their hands at prescribed ‘moments’ for hand hygiene.

The WHO moments for hand hygiene for healthcare workers include:

1. Before patient contact
2. Before performing an aseptic task
3. After body fluid exposure risk
4. After patient contact
5. After contact with patient surroundings

Evidence from the field suggests that for institutions with typically abysmal hand hygiene rates, implementation of these policies have led to significant reductions in hospital-acquired infections. However, implementing these policies in institutions with mediocre hand hygiene rates produces less significant decreases in hospital infection rates.

Despite improvements in hospital-acquired infection rates, the WHO moments of hand hygiene, to which most hospital hand hygiene auditing systems are aligned, may not adequately capture the myriad of opportunities for cross-contamination of surfaces. Of particular note, the WHO moments do not include staff restroom visits, and as a result, this is neither measured nor targeted for improvement.

Patient hand hygiene has been wholly ignored by policy makers, yet there are easy things that a hospital can do to promote patient hand hygiene:

  • Educate patients to be worried about the risks their hands represent. If they were aware, patient hand hygiene compliance rates might increase dramatically.
  • Make hand hygiene easy for patients. Provide bedsideaccess to hand sanitizer or disinfectant wipes with meals.
  • Measure ongoing patient hand hygiene within the overall quality improvement plan.

In an article published in the American Journal of Infection Control (May, 2012), author Timothy Landers recommends these 9 ‘moments’ for patient hand hygiene:

9 Moments for Patient Hand Hygiene

1. After using the toilet, bedpan, or commode
2. When returning to room after test or procedure
3. Before eating, drinking, taking medicine, or putting anything in your mouth
4. When visibly dirty
5. Before touching any breaks in the skin (e.g. wounds, dressing, tubes) or any care procedures (e.g. dialysis, IV drug administration, injections)
6. Before dialysis, contact with IV lines or other tubes
7. After coughing, sneezing, or touching nose or mouth
8. Before interacting with visitors and after they leave
9. When there is concern about whether hands are clean

If everyone in the hospital considers the moments that might be critical in their own hand hygiene, we may see even better results in the battle against hospital-acquired infections. Patients need to be educated about the dangers their hands represent, and they need to be empowered to protect themselves by providing them with hand sanitizer where and when it is needed. Promoting patient hand hygiene is not only an easy step toward better patient safety, it is logical, necessary and urgent.

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Show Me Your Hands: Hand Hygiene Myths and Facts
https://infectioncontrol.tips/2015/12/08/1210/

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References:

Barker, Anna et al (2014, May). Patients’ Hand Hygiene at Home Predicts Their Hand Hygiene Practices in the Hospital [from Infection Control and Hospital Epidemiology, Vol. 35, No. 5 pp. 585-588]. Retrieved from https://www.medicine.wisc.edu/sites/default/files/hand_hygeine_safdar.pdf

Grayson, Lindsay et al (2011) Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative [from Medical Journal of Australia v.195 (10): 615-619]. Retrieved from https://www.mja.com.au/journal/2011/195/10/outcomes-first-2-years-australian-national-hand-hygiene-initiative?0=ip_login_no_cache%3D22216580f0a1e1c8e1eb066ee054a0af

Improved Hand Hygiene to Prevent Health Care-Associated Infections http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution9.pdf

Landry, Timothy et al (2012, May). Patient-centered hand hygiene: The next step in infection prevention. [article in American Journal of Infection Control, v. 40, Issue 4, Pages s111-s17]. Retrieved from http://www.sciencedirect.com/science/article/pii/S0196655312001514

Srigley, Jocelyn A., Colin D. Furness and Michael Gardam (2014, November). Measurement of Patient Hand Hygiene in Multiorgan Transplant Units Using a Novel Technology: An Observational Study

[from Infection Control and Hospital Epidemiology Vol. 35, No. 11 pp. 1336-1341]. Retrieved from http://www.jstor.org/stable/10.1086/678419#full_text_tab_contents

WHO Guidelines on Hand Hygiene in Healthcare (2009). Retrieved from http://www.who.int/gpsc/5may/background/5moments/en/

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Niall Wallace
Niall Wallace is a co-founder and the Chief Innovation Officer of Infonaut Inc. Infonaut is a privately held Canadian company with Canadian locations in Toronto, and Hamilton Ontario, with US offices in Buffalo New York. Born out of Ontario’s SARS crisis, Infonaut solves the global challenge of deadly hospital infection through their proprietary real-time surveillance, analytics and behavior improvement platform. Niall has used his background in population health, public health, data-warehousing and privacy to develop deep expertise in innovative platforms that use the power of location technology, and B.I. systems for disease and infection surveillance.

5 COMMENTS

  1. This matches my experience as a patient. I was unable to get to a sink to wash my hands so had the alcohol hand gel placed within easy reach. However, when I was moved to another ward, it was repeatedly moved out of my reach because “it wasn’t in its proper place”.

    At work, my main question is about intravenous cannulae. A general policy is to place them as distally as possible so that, as they need to be re-sited, as many alternative sites as possible remain. However, does anyone have any evidence of the impact of this on hand-hygiene for patients feeding themselves? I’m not allowed to wear a wristwatch on the ward in case this affects my ability to wash my hands effectively so should we be avoiding cannulae in the hands for self-caring patients?

  2. We have to be careful about providing direct clinical advice. Without making a clear recommendation against cannula sitting on the hand (because we’re not qualified to say so), we can say that whenever possible patients’ ability to wash their hands should be facilitated, not impeded. When the presence of a cannula (or any other device) does mean that hand washing cannot happen, then it becomes even more important to make hand sanitizer available. Additionally, hospitals that we have worked with have adopted nurse-actioned patient hand cleaning protocols for unconscious or semi-lucid patients. Bottom line: preventing patients from cleaning their hands puts them at increased risk for infecting themselves.

  3. It is also important to remember that as a resource, the provided information is for the majority of situations. Each institution has set up their own guidelines which have (hopefully) been modified to the risks that they face.

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