The COVID-19 pandemic adds impetus to a longstanding mission of a nurse scientist: getting hospitalized patients to wash their hands. Somewhat surprisingly, this commonsense measure is not in effect at many facilities, although it is known that patients can contaminate their own invasive lines and self-inoculate infections.
“We know from data from all over the world that patients’ hand hygiene practice is very poor,” says Shanina C. Knighton, PhD, RN, an instructor and researcher at Case Western Reserve University in Cleveland, OH. “Patients’ hand hygiene is even lower than some of the worst healthcare compliers — less than 40% at times.”
The Centers for Disease Control and Prevention (CDC) recommends that hospital patients wash their hands for their own protection, but hospitals are not required to provide information to patients about cleaning their hands, she notes. “As a patient in a healthcare setting, you are at risk of getting an infection while you are being treated for something else,” the CDC states.1 “Patients and their loved ones can play a role in asking and reminding healthcare providers to clean their hands. Your hands can spread germs too, so protect yourself by cleaning your hands often.”
The CDC recommends patients wash their hands at regular intervals, including:
- before preparing or eating food;
- before touching their eyes, nose, or mouth;
- before and after changing wound dressings or bandages;
- after using the restroom;
- after blowing their nose, coughing, or sneezing;
- after touching hospital surfaces, such as bed rails, bedside tables, doorknobs, remote controls, or the phone.
Proposed State Law
How serious is Knighton about this topic? Recently, she worked to get a state law introduced in Ohio that would require handwashing education for patients and long-term care residents. “[This] bill is the first in the nation asking for mandatory patient hand hygiene education in hospitals and in long-term care facilities,” she says. “Science does no good if it is sitting on a shelf.”
Introduced by Ohio Rep. Juanita Brent (D-Cleveland), the Hand Hygiene Education Bill would require using educational materials to teach patients and residents to independently decontaminate their hands with alcohol rubs or soap and water. The bill calls for healthcare staff to assist patients and residents with hand hygiene if they cannot independently wash their hands.
“This is a piece of legislation that was in the works prior to the COVID-19 pandemic,” Brent said in a statement. “I have been collaborating with Dr. Knighton on this bill to improve patient and resident hand hygiene. Good hand hygiene must be practiced now to help combat the spread of the COVID-19 virus.”
Knighton is the lead author of a recently published study that assessed patients’ hand hygiene practice in a survey administered in post-discharge visits.2
Patients were asked to provide their perspective on the importance of patient hand hygiene compared with hospital staff, as well as their satisfaction or lack thereof with hand hygiene independence.
Overall, 65 (61%) of the 107 respondents reported that prior to being admitted to the hospital, they were able to maintain cleaning their hands with little or no difficulty.
“During their admission, only 21 (19.6%) of the participants reported needing little or no assistance,” the researchers found. “More than one-half of the participants, 34 (32%) and 23 (22%), respectively, reported mostly or completely agreeing that the hand hygiene of the healthcare staff was more important than their own.”
Fifty (47%) participants were not satisfied with their ability to maintain their hand hygiene in the hospital. Ten (9%) were very satisfied with their ability to maintain hand hygiene.
“In surveys, patients often attribute their poor hand hygiene practices primarily to staff being too busy to provide assistance and lack of access to hand hygiene products,” the authors note.3-5 “Despite healthcare settings being one of the most likely places to acquire or transmit pathogens, patients are not included in routine hand hygiene practice.”
With the efficacy of hand hygiene in healthcare workers well established “no hands should be ignored” in hospitals and nursing homes, Knighton emphasizes. “For example, patient-centered education around infection prevention is needed so that patients do not believe that hand hygiene resources around the hospital are only meant for health care staff,” the paper concludes.
Hospital Infection Control & Prevention (HIC) asked Knighton to comment further on this issue in the following interview, which has been edited for length and clarity.
HIC: When this subject comes up, there often are concerns expressed that impaired patients and those with dementia may try to consume or otherwise misuse alcohol hand rubs.
Knighton: Right, but we’re not talking about all patients. The United States has about 150 million admissions each year. How many of those are people who can adequately clean their hands?
The other piece of it is that we know that healthcare workers’ hands can become contaminated. We know that the environment surrounding the patient is contaminated — their bedside tables, call lights, bed rails that they commonly touch. For a catheter insertion, a wound change, we may use the patient’s bedside table. There are a lot of contamination elements. [There have been reports] of finding COVID on doorknobs, bedrails, and call lights.
These are the same concerns we acknowledge for the pathogens that lead to healthcare-associated infections. We have public health initiatives right now saying everybody clean their hands, but some of our vulnerable patients cannot clean their hands. Are we neglecting their ethical rights?
HIC: You mentioned the CDC recommendations in this area, and you have a paper emphasizing four moments for patient hand hygiene.6
Knighton: Yes, we understand that some healthcare systems are limited. Everyone is not going to provide every patient with a bottle of hand sanitizer. We get that, but start with the basics of education. [Patients] can practice hand hygiene when [eating] their meals, going to the rest room, when they are coming in and out of their rooms, and also if they are touching any wounds or medical devices.
Right now, a lot of hospitalized patients wait for their healthcare workers to tell them everything, including their hand hygiene [recommendations]. Our study asked them to reflect, after they are admitted, on what their hand hygiene practices were. Were you provided any materials? Did you independently clean your hands?
A lot of patients were aware of hand hygiene from a prior profession or because this is just a norm for them. It ends up being a situation of where they know the sink is there and the hand sanitizers are on the wall, but they think they are for healthcare workers, not them.
HIC: You have found that this is a longstanding blind spot in infection control practice.
Knighton: If the hand sanitizer is located on the wall and the patient can’t get to it, does it just mean that we shouldn’t clean their hands? I think that has been the norm, because it has been ignored for so many years. When I look back at studies from the 1960s and 1970s — these were monumental studies that informed infection prevention right now — they mention the fact that patients have germs on their hands. In some cases, they note that the patients are the original carriers of these germs. But the conclusion — and you can tell that it is biased — is that healthcare workers should clean their hands [because] patients may be a route of transmission. If the results suggest that the patient was the original carrier, why is it suggested that only healthcare workers clean their hands? There are studies that show patients bring in germs to emergency departments (EDs), comparing the different strains of MDR0s (multidrug-resistant organisms) inside the hospital from those found in the ED.
HIC: There certainly have been campaigns for patients to “speak up” and remind healthcare workers to disinfect their hands. Perhaps there is some concern that patients would be alarmed if warned about the pathogens in the hospital environment?
Knighton: We are talking about a nation where healthcare-associated infections affect about 2 million people [per] year and cause 100,000 deaths. If you can tell a patient to tell their providers to clean their hands, then you have already disclosed that there are germs in the hospital. One reason I say that patient education is important is that right now the burden falls on nurses because they are closest to the patient. They may choose to do it or not to do it. But there are strategies that can be employed, such as [bringing] everyone as a caregiver that interacts with the patient and educating the patient themselves. Patients may require physical therapy, so get physical therapy on board to help clean their hands. When nurses come in the room and they are cleaning their hands, they can [prompt] the patient to clean their hands. The study showed that a lot of patients had practiced hand hygiene at home, but if they are under the impression that the materials are not meant for them, then they don’t have the knowledge to practice hand hygiene at the minimum they need.
HIC: Historically, changing practices in infection control, and medicine in general, have been notoriously difficult.
Knighton: In this instance, I can tell you since 2009-2010 I have met resistance. I don’t want this to be the [Ignaz] Semmelweis reflex 2.0. That man was working very hard to try to get people to clean their hands, and it was ignored because it was not deemed important. If I am a patient, cleaning my hands not only helps prevent potential infections, but it means I can be engaged [in my care] instead of waiting or hoping that someone can keep me safe. Patients assume that the environment is going to be clean and their healthcare workers are going to clean their hands. We are talking about human-based actions that can lead to error. Why wouldn’t we provide them with another strategy to protect themselves before they end up infected? Again, is it ethical to not provide patients with hand hygiene education and adequate materials?
- Centers for Disease Control and Prevention. Clean Hands Count for Patients. March 15, 2016. https://www.cdc.gov/handhygiene/patients/index.html
- Knighton SC, Richmond M, Zabarsky T, et al. Patients’ capability, opportunity, motivation, and perception of inpatient hand hygiene. Am J Infect Control 2020; 48:157-161.
- Cao J, Min L, Lansing B, et al. Multidrug-resistant organisms on patients’ hands: A missed opportunity. JAMA Intern Med 2016;176:705-706.
- Mody L, Washer LL, Kaye KS, et al. Multidrug-resistant organisms in hospitals: What is on patient hands and in their rooms? Clin Infect Dis 2019;69:1837-1844.
- Rai H, Saldana C, Gonzalez-Orta MI, et al. A pilot study to assess the impact of an educational patient hand hygiene intervention on acquisition of colonization with health care-associated pathogens. Am J Infect Control 2019;47:334-336.
- Sunkesula VCK, Knighton S, Zabarsky TF, et al. Four moments for patient hand hygiene: A patient-centered, provider-facilitated model to improve patient hand hygiene. Infect Control Hosp Epidemiol 2015;36:986-989.