Handwashing - Water, Foam, Gel? Frequency and Technique Still Critical
Monday September 23, 2002
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"Nurses and all other healthcare workers put themselves and their patients at risk when they don't wash their hands," says Georgia Dash, RN, MS, CIC, president of the Association for Professionals in Infection Control and Epidemiology, Inc., and director of epidemiology and infection control at the Medical College of Pennsylvania Hospital in Philadelphia.
Bedside nurses agree. In a detailed survey, "protection of self" and "fewer patient infections" were the most likely reasons nurses gave for washing their hands, especially if their patients were known to be infected. A "good annual evaluation" was the least important reason. Nurses were most deterred from handwashing by concern about dry, sore hands. They were least likely to wash their hands when a crisis demanded immediate attention.2
Most nurses overestimate how often they wash their hands - they say they wash up to three times more often than they actually do.2 Overall, healthcare workers comply with handwashing policies only about 40% of the time. Studies show healthcare workers on average wash their hands only five to 30 times during a work shift, but some nurses wash as often as 100 times.3
When situations require more frequent handwashes, nurses don't keep up. ICUs presented the greatest number of opportunities requiring handwashing - 20 opportunities an hour, on average - but led to the lowest adherence to handwashing, just 36%. Pediatric units had the lowest number of opportunities - just eight for each patient during an hour - but adherence to handwashing climbed to 59%. Another study found healthcare workers in a short-staffed ICU washed their hands only 25% of the time during busy work periods, but compliance jumped to 70% when staffing improved.3
Are nurses or the ancillary personnel they supervise lulled into a false sense of security by gloves? Some hospital personnel foolishly load their hands with layers of disposable gloves they then peel off one at a time after each patient or task. How many nurses remove their gloves and wash their hands before reaching for the phone or a pen? "Gloves offer just a gross protection," Dash says. "If you looked under a microscope, you would see holes. Even when you wear gloves, you must still wash your hands."
Many hospitals turn to alcohol-based handrubs to save time and put hand cleaners closer to patients to avoid costly new plumbing. This strategy seems to work. Studies show ICU nurses were more likely to use readily available alcohol-based handrubs, although physicians still failed to either wash their hands with soap and water or use alcohol-based handrubs.4 Alcohol hand gels irritated nurses hands less than soap and water.5 Nurses grew fewer bacteria on their hands when they used alcohol-based handrubs or antiseptic soap rather than nonantiseptic soaps.6 Most importantly, patients in an extended-care facility had a third fewer urinary tract, wound, and respiratory infections on units where nurses used alcohol-based handrubs.7
Alcohol-based handrubs are still far from foolproof. Many healthcare workers wash too briefly and often miss important parts of their hands and fingers, habits that also make alcohol-based handrubs ineffective.3 Not all alcohol-based products provide the same degree of protection. A comparison of the antimicrobial efficacy of 10 alcohol-based gels and four rinses found none of the gels met established standards for adequately sanitizing hands.8 Although handrub systems are usually cheaper than adding plumbing, the dispensers must still be refilled and remain unclogged.
Regardless of the method nurses use to wash their hands, they encounter more situations that call for hand hygiene than they have in the past. Research shows disease-causing bacteria spread more easily than previously assumed. In one study, nurses palpated the femoral pulse of a patient who had intact but moist skin that was heavily colonized with pathogenic bacteria. After washing their hands with soap and water, the nurses handled urinary catheters. Researchers cultured the same pathogenic bacteria from the catheters, despite the nurse's efforts to clean their hands.3
Handwashing alone isn't enough to control antibiotic-resistant bacteria, especially vancomycin-resistant Enterococcus (VRE). Enterococci are the second most commonly hospital-acquired blood infection, and at least a quarter of cultures are resistant to vancomycin.9 "With VRE, you should wear gowns and gloves when you just walk into the room," says Dash. "We know it survives on equipment and bed curtains for seven days." Research shows using cover gowns in addition to gloves reduced the transmission of VRE more than twofold.9
No one knows exactly why so many nurses fail to wash their hands enough. Are nurses stuck between the high-bar standards of policies and procedures and the low-bar realities of inadequate staffing and sick patients with unpredictable crises that require immediate attention? To follow hand hygiene policies exactly, many nurses would need an extra hour to wash their hands for every hour they spend delivering care. Are nurses who claim they have too little time to wash really voicing a socially acceptable excuse? Or are they playing out a "culture of low expectations," a term initially used to explain poor communication and medical errors? Tired and overworked nurses may easily conclude it's impossible to do the job right and toss up their hands in frustration.
Jeffrey Zurlinden, RN, MS, is a frequent contributor to Nursing Spectrum.
References
1. Berens MJ. Infection epidemic carves deadly path. Chicago Tribune. July 21, 2002;A-1,A-14,A15.
2. O'Boyle CA, Henly SJ, Duckett LJ. Nurses' motivation to wash their hands: a standardized measurement approach. Appl Nurs Res. 2001;14(3):136-145.
3. Boyce JM, Pittet D. Draft Guideline for Hand Hygiene in Healthcare Settings. 2001. Developed by the Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee, the Society for Healthcare Epidemiology of America, the Association for Professionals in Infection Control and Epidemiology, and the Infectious Diseases Society of America.
4. Hugonnet S, Perneger TV, Pittet D. Alcohol-based handrub improves compliance with hand hygiene in intensive care units. Arch Intern Med. 2002;162(9):1037-1043.
5. Boyce JM, Kelliher S, Vallande N. Skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water hand washing versus hand antisepsis with an alcohol hand gel. Infect Control Hosp Epidemiology. 2000;21(7):442-448.
6. Lucet JC, Rigaud MP, Mentre F, Kassis N, Deblangy C, Andremont A, Bouvet E. Hand contamination before and after different hand hygiene techniques: a randomized clinical trial. J Hosp Infect. 2002;50(4):276-280.
7. Fendler EJ, Ali Y, Hammond BS, Lyons MK, Kelley MB, Vowell NA. The impact of alcohol hand sanitizer use on infection rates in an extended care facility. Am J Infect Con. 2002;30(4):226-233.
8. Kramer A, Rudolph P, Kampf G, Pittet D. Limited efficacy of alcohol-based hand gels. Lancet. 2002;359(9316):1489-1490.
9. Srinivasan A, Song X, Ross T, Merz W, Brower R, Perl T. A prospective study to determine whether cover gowns in addition to gloves decrease nosocomial transmission of vancomycin-resistant enterococci in an intensive care unit. Infect Control Hosp Epidemiology. 2002;23(8):424-428.
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