Hand washing may suffer in understaffed settings

Keeping patients from picking up an infection during their hospital stay is a concern to everyone involved with patient care — and it can start with something as basic as washing your hands.

Recently, researchers attempted to identify predictors of noncompliance with hand washing during routine patient care in a 1,300-bed teaching hospital in Geneva, Switzerland. They examined the activities of 520 nurses, 158 physicians, 166 nursing assistants, and 199 other types of health care workers caring for 964 (70%) of the beds in December 1994. Five trained observers noted the number of opportunities for hand washing that presented themselves after each patient contact; between care of a dirty body site and a clean one; after contact with body fluid; before and after care of an intravenous site, a wound, the respiratory and urinary tract, as well as after glove removal; and after any activity involving indirect patient contact or hospital maintenance. They also noted how often hands were actually cleansed. The hospital guidelines recommended that hands be washed with soap and water or be disinfected before and after patient contact. They also should be washed after removing gloves and after contact with a potential reservoir of microorganisms such as body fluids and substances, mucous membranes, broken skin, or inanimate objects that are likely to be contaminated.

Average compliance was only 48% of the 2,834 observed opportunities for hand washing, with physicians being least compliant (30%) and nurses being most compliant (52%). Compliance was better on weekends (59%) than during weekdays (46%) and worst in intensive care units (36%), with medical and surgical wards being 47% to 52% compliant.(See related story, p.54.)

Similarly, hands were least likely to be cleansed after procedures involving a high risk of contamination (38%) than after other procedures (49% to 52%) and when the intensity of patient care was high (37% for more than 60 opportunities for hand washing compared with 58% for less than 20 opportunities). The researchers concluded that the moderate compliance with hand washing might be explained by the intensity of care, suggesting that understaffing may lower the quality of patient care. An editorial accompanying the publication of the survey’s results called for expanded study of the possible role of alcohol-based, bedside hand rinses and gels, which could reduce the time required for hand washing and make it more feasible for caregivers with high workloads to wash their hands more frequently.

Comment by J. Peter Donnelly, PhD, clinical microbiologist, University Hospital Nijemen, the Netherlands.

With nosocomial infections complicating as many as one in 10 hospital admissions, the problem is not negligible. Since the days of Ignaz Semmelweis, the medical community has been confronted with the simple truth: "clean hands = fewer infections." Why then did only half of the health care workers follow this simple rule? The answer may well lie in the fact that they are all too busy. This is almost certainly true for those nurses who have to care for patients’ clean and dirty body sites and are most likely to wash hands once they have finished rather than in between each and every step in the patient’s care. [The researchers] point out that it takes eight to 10 seconds to wash the hands and might take one minute to go from the patient to the sink, wash their hands, and return to their patient. Nearly half of the observed opportunities to wash hands occurred when patient care was at high intensity (21 to 40 hand washing opportunities per hour), occupying a prohibitively large amount of the working hour. This is reinforced by the better compliance observed on weekends when hospitals run a less intensive service and the extremely poor compliance seen during the care of critically ill patients, thus confirming the perception that health care workers are often too busy to wash their hands as recommended.

An organizational issue

There is a relationship between the intensity of patient care and noncompliance with hand hygiene recommendations, meaning hand washing is not only a matter for the individual but also for the organization. Reducing workloads would, therefore, seem a necessary part of the solution to the problem of failure to wash the hands. In an accompanying editorial, the writer emphasized that hospital administrators should strive to create an organizational atmosphere in which adherence to recommended hand hygiene practices is considered an integral part of providing high-quality care. Strangely, [the writer] did not mention improving staff/patient ratios, not even for nurses who are perceived to be the most likely to cross-infect patients because of the nature of their contact with patients. Rather, he suggested that a record of adherence to hand hygiene recommendations should form a part of the annual personnel evaluation. Clearly, it is intolerable that hand washing is still neglected to almost the same extent as it was in Semmelweiss’ day, and it is time for hospitals to get serious about improving hand hygiene. But if there really is not enough time to comply with hand hygiene, it is hard to see a solution while there continues to be a drive toward maximizing productivity by employing fewer people to care for more patients in a shorter period of time.

Suggested readings

1. Pittet D, Mourouga P, Perneger TV, et al. Compliance with hand washing in a teaching hospital. Ann Intern Med 1999; 130:126-130.

2. Boyce JM. Editorial. Ann Intern Med 1999; 130:153-155.