Hand hygiene effectiveness in hospital infection control

It seems crazy to think that we haven’t always been aware of the important role hand hygiene plays in preventing the spread of infection.

When Hungarian doctor Ignaz Semmelweis started to champion this idea back in the 1880s, he was largely ignored.

Despite various publications of results showing hand washing reduced mortality to below 1%, Semmelweis’ observations continued to be rejected by the medical community. His findings just didn’t match up to the established scientific and medical opinions at the time.

Today, you’d be shocked if you walked into a hospital and weren’t confronted with alcohol gel dispensers and calls to wash your hands everywhere you turn. It is now universally acknowledged that the hands are the principal route by which cross-infection occurs.

Hand hygiene is such an important part of the healthcare practice, that it’s hard to believe it hasn’t always been a priority.

But still, is hand hygiene being taken seriously enough?

Despite hand hygiene being the single most important intervention that hospital workers can undertake to prevent hospital-associated infections (HAIs), there is a vast amount of evidence that shows compliance is low, with hands being washed either infrequently or inadequately.

We explore how cross-infection via the hands occurs, the effectiveness of hand hygiene in controlling the spread of infection, and what we can do to improve hand hygiene in hospitals.

How cross-infection via the hands occurs

There are two types of bacteria that can be found on the hands. Resident skin flora consists of microorganisms that are found on the surface of the skin. Transient skin flora does not reside on the skin but can be acquired and transferred by touch. MRSA and C.difficile are both examples of microorganisms that can both be carried on the hands transiently. These bacteria can survive on hands for up to 150 hours.

According to the World Health Organisation (WHO), transmission occurs via the following steps:

• Organisms are present on the patient’s skin or have been shed onto objects or equipment immediately surrounding the patient
• Organisms are transferred to the hands of the healthcare worker
• Organisms survive at least several minutes on the healthcare worker’s hands
• Hand washing or hand antisepsis by the healthcare worker is inadequate or omitted entirely
• The contaminates hand(s) of the healthcare comes into contact with another patient or an object or equipment that comes into direct contact with the patient.

The effectiveness of hand hygiene in infection control

Hand hygiene is considered the single most important factor in the control of infection. It protects patients and healthcare workers from acquiring microorganisms that may cause them harm.

‘Good’ hand hygiene practice is estimated to reduce the spread of HAIs by 15-30%.

Hand hygiene can be performed with liquid soap and water (for cleaning soiled hands), antiseptic solution and water (before and after invasive surgeries) or by using alcohol-based hand rubs or gels (for hands that are visibly clean).

The use of alcohol hand rubs and gels have now become the gold standard for routine hand decontamination and should be used routinely when hands are visibly clean. They are active immediately against a wide range of microorganisms and can be used for surgical hand decontamination too. However, they are not a cleansing agent and are ineffective against bacterial spores. Hand washing, on the other hand, effectively removes transient organisms.

Both hand washing and the use of alcohol-based hand rubs and gels are equally important, and there is a place for both in the hospital environment.

The first study to really prove the value of this multimodal hand hygiene strategy was published in 2000 and demonstrated significant hospital-wide hand hygiene compliance and improvement, which was associated with an overall reduction in HAIs, including MRSA.

It was this study that led to the 2009 WHO Hand Hygiene Improvement Strategy, which included the development of the ‘5 Moments of Hand Hygiene’ approach that has been adopted by hospitals and other healthcare environments across the globe.

But are we taking hand hygiene seriously enough?

Of course, doctors and nurses know that germs spread infections and that hand hygiene is critical in preventing it. But that doesn’t necessarily mean hospital workers are washing their hands and using alcohol-based rubs or gels as often as they should.

A global study from 2010 found that just 40% of healthcare workers comply with recommended hand hygiene guidelines which, at the very least, promote proper hand hygiene before and after contact with a patient.

There are plenty of reasons hand hygiene may be overlooked. Sinks or alcohol hand rub dispensers aren’t always conveniently located in the hospital, there may not be soap in the dispenser, or workers may be concerned about drying out their skin. Some people may still need convincing that hand hygiene is crucial. Plus, it may sometimes be overlooked given all the other tasks that demand a healthcare worker’s attention in a busy hospital environment.

Improving hand hygiene in hospitals

The simplest thing hospitals can do to increase hand hygiene is to invest in alcohol-based hand rubs and gels. In fact, studies have shown that introducing personal bottles can increase compliance rates significantly.

But this has to be supported by clear messaging around the importance of hand hygiene in reducing the spread of HAIs. Educate hospital staff on how susceptible they are to acquire an infection if they don’t follow effective hand hygiene practice, and how serious those infections can be.

Training initiatives around best practice and the benefits of hand hygiene are important too. Use real-life, personal stories regarding the human cost of HAIs to appeal at an emotional level.

Hand hygiene is the single most important intervention that hospital workers can undertake to prevent HAIs. Hands are frequently implicated in cross-infection and effective hand hygiene is critical for protecting patients, staff and visitors from acquiring potentially pathogenic microorganisms. When hospital workers comply with hand hygiene practices, it can drastically reduce the spread of HCAIs.