Though it is a practice as often ignored as observed, hand hygiene remains the cardinal principle of infection control. The cross-transmission of pathogens between patients due to transient colonization on healthcare workers’ unwashed hands has caused many infections, some of them fatal.
We know intuitively that this worst of all outcomes is possible, but hand hygiene compliance is not typically linked to mortality data.
However, a new study in 26 French nursing homes found that a multifaceted hand hygiene program including staff, residents, and visitors did indeed reduce mortality.
From April 1, 2014, through April 1, 2015, researchers randomly assigned 13 nursing homes to an intervention group, with the other half serving as the control arm.
The hand hygiene intervention eased compliance by distributing pocket-sized alcohol hand rub dispensers. New wall dispensers were added in the facilities and the awareness effort included education and posters.
In addition, each facility participating in the intervention formed a small hand hygiene work group to focus on the problem.
The intervention group that emphasized hand hygiene measures had 21% less mortality than the control group. Of particular note, the morality reduction rose to 30% during a three-month period in 2015 when France was experiencing a severe flu outbreak.
Improved hand hygiene also had a downstream effect of reducing antibiotic prescription rates in the intervention group, which, not surprisingly, also had higher use of hand hygiene rubs during the study. For two months prior to the study, this product-used measure was roughly equal between the facilities in both research arms.
Unfortunately, the evidence of reduced mortality faded as the hand hygiene emphasis was discontinued. This inability to “sustain the gain” is typical of hand hygiene interventions, as compliance often reverts to baseline after the quality improvement effort is stopped. Nevertheless, the study shows that hand hygiene can save lives, a connection that was originally made by the 19th century physician who first proved the efficacy of the practice.
“Usually, it is very hard to say that the reason people died was lack of hand hygiene,” says Janet Haas, PhD, RN, CIC, FSHEA, FAPIC, 2018 APIC President. “Other than Semmelweis, who did a nice job with that, and that’s how this whole thing started.”
Indeed, Hungarian physician Ignaz Semmelweis (1818-1865) famously made the connection between hand hygiene and mortality when trying to stop an outbreak of puerperal fever in women at childbirth. As noted in the medical literature, “he ordered a new handwashing procedure as an experiment. All medical students were instructed to wash with chlorinated lime before any examination. The fever deaths promptly declined.”2
As IPs are aware, the story does not end well. Semmelweis was something of a prophet unwelcomed in his own land, drawing widespread scorn from colleagues who felt they were being blamed for patient deaths. This was in an era before the germ theory — which, of course, subsequently established that Semmelweis was right.
The specific pathogen causing the deaths of the women at childbirth was identified as Streptococcus pyogenes.
While hand hygiene is an area of ongoing emphasis in hospitals, particularly since the widespread adoption of alcohol hand rubs over soap and water, nursing homes are becoming a focus of increasing infection prevention.
According to APIC, U.S. nursing homes report some 3 million infections per year, suggesting hand hygiene efforts like those demonstrated in the French study could have a major impact.
“We definitely know that [lack of] hand hygiene is linked to hospital infections, but people are also at risk in these non-acute care settings,” Haas says.
“In nursing homes, it is little bit easier to assess [hand hygiene] than in hospitals, where there are so many things going on that are invasive and interventional for patients in acute care,” Haas adds.
“When you get into the nursing home settings, it is really where people live, and so community infections can spread to this vulnerable population. We know that hand hygiene is a way to [prevent] that.”
- Temime L, Cohen N, Ait-Bouziad K, et al. Impact of a multicomponent hand hygiene-related intervention on the infectious risk in nursing homes: A cluster randomized trial. AJIC 2018;46(2):173–179.
- Mannoia VJ. What is Science? An Introduction to the Structure and Methodology of Science. University Press of America: Washington, DC; 1980.