The Forgotten Art and Science of Hand Hygiene

Abstract & Commentary

Synopsis: This concise review makes a compelling case for a change in the healthcare worker’s behavior. Helpful hints including increasing the use of alcohol-based formulations to reduce the time constrains are provided throughout the article.

Source: Trampuz A, et al. Mayo Clin Proc. 2004;79: 109-116.

Nosocomial infections have become the Achilles heel for the healthcare industry. Numerous scientific and lay public articles cite the increasing frequency of nosocomial infections. The problem and the solution, however, have been known for a long time. As Trampuz and colleagues review in the article, Semmelweis proposed more than 150 years ago that the results of hospital care (in that case, a maternity ward) could be dramatically improved by using careful hand washing with a 4% solution of chlorinated lime. The microbiology of skin flora was not well defined at that time. It is now known that there are normal resident flora, a group of organisms (coagulase-negative staphylococci, corynebacteria, etc) that colonize the deeper layers of skin. These organisms are hard to get rid of by hand washing, but they prevent colonization of deeper tissues by more virulent or pathogenic microorganisms. Transient flora, a group of organisms that colonize more superficial layers of skin, are responsible for most health care related infections and the spread of antimicrobial resistance. This group includes organisms such as Staphylococcus aureus, Gram-negative bacilli and Candida species amongst them. There are 2 different methods for hand hygiene. In the traditional method, hands should be washed thoroughly with soap and water for at least one minute, and a disposable towel should be used to dry hands and perhaps to close the faucet. With mechanical friction, microorganisms are removed from the skin and hair follicles. It is now thought that such careful hand washing is essential only when hands are soiled with body fluids.

In general, it takes approximately 2 minutes to complete such a hand-washing task. It is estimated that if good hand washing is performed for 3 episodes per hour, nurses may have to spend about one fifth of their time washing hands during an 8-hour shift.

The emerging alternative is alcohol-based hand rubbing solutions and gels. The use of alcohol-based hand rubs is being recommended in most other circumstances in which hand hygiene is required. Alcohol has bactericidal properties that most hand washing soaps do not have. A much shorter time is needed to achieve a significant reduction in bacterial colony counts when using alcohol based hand rubs. These products also have some important virucidal activity. Also, alcohol-based hand rubs can be used while traveling between the points of contact with the patient to other areas of work, or even while traveling to the next patient.

The use of powder-free gloves reduces the need for hand washing; however, it does not obviate the need for hand hygiene. Alcohol-based hand rubs should be used after removing gloves. Needless to say, a new pair of gloves should be used for each patient contact. Trampuz et al suggest that alcohol-based hand rubs are also easier on hands than repeated washing with soap and water. Alcohol rubs should be stored away from high temperatures. At present, it is thought that the emergence of microbial resistance is less likely against alcohol-based formulations. It is important to remember that alcohol based hand rubs are to be used only when direct contamination of hands with body fluids has not occurred. The risk of wearing rings and artificial fingernails, which may act as harbingers of bacterial contamination, is highlighted in the article. Based on the available scientific evidence, Trampuz et al suggest that alcohol-based hand rubs should be used liberally and regularly to reduce nosocomial infections.

Comment by Uday B. Nanavaty, MD

Good hand hygiene by health care personnel is vital to reduce nosocomial infection rates. Maintaining good hand hygiene is a moral duty as well. Unfortunately, routine compliance rates with good hand hygiene are ridiculously low. Most studies suggest that hand hygiene compliance rates in hospital settings are between 20 to 40%. Hospital and system wide projects including education and surveillance by camera and other electronic devices improve compliance rates. Unfortunately, even with these expensive interventions, compliance rates approach only about 70% at best. Imagine if restaurant workers had hand hygiene rates of 40% or less! The country would be reeling with gastro-intestinal morbidity and the food industry would be out of business. Before the bugs on our hands get us out of our business, it is important that we get rid of them, as best and as frequently as possible.

Dr. Nanavaty is a Doctor of Pulmonary and Critical Care Medicine, National Institute of Health, Rockville, Maryland.