J R Soc Med 2001;94:278-281
© 2001 Royal Society of Medicine
Hand hygiene—the case for evidence-based education
S P Stone MD FRCP
Academic Department of Geriatric Medicine, Royal Free Campus, Royal Free
and University College Medical School, London NW3 2PF, UK
E-mail:
s.stone{at}rfc.ucl.ac.uk
 |
INTRODUCTION
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Among the priorities identified for the National Health Service
(NHS) are
reductions in hospital-acquired infection and in antimicrobial
resistance
1.
These
are to be achieved by improved surveillance, optimal antibiotic
prescribing
and strengthening of basic infection control procedures
such as handwashing.
According to recent
figures
2,3,
hospital
acquired infection affects 1 in 11 inpatients, carries a 13%
mortality
and lengthens stay by a factor of 2.5. The extra cost to the
NHS is
nearly £3000 per patient, and the total annual
cost is nearly £1
billion. Between 15% and 30% of hospital-acquired
infection is considered
preventable, but even a 10% reduction
would improve bed management to the tune
of 47ooo extra finished
consultant episodes per year. The NHS's action plan to
reduce
hospital-acquired
infection
4 holds
chief executives personally
accountable, and requires handwashing to be
implemented in line
with Department of Health
guidance
5,6.
Healthcare workers' compliance with handwashing is known to be poor, with
doctors performing particularly
badly7,8.
When the Department of Health published its handwashing guidance a storm of
correspondence in the BMJ excused low compliance on grounds of lack
of time, poor availability of sinks and soaps, skin sensitivity and lack of
evidence. This paper reviews the evidence that patient contact results in
contamination of the hands by pathogens and that washing with liquid soap and
water or, better, use of an alcohol handrub, greatly reduces hand
contamination and infection rates, and presents the case for making hand
hygiene a medical educational
priority9.
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BACKGROUND
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Semmelweis
The first clear evidence of clinical benefit from hand hygiene
came from
Semmelweis, working in the Great Hospital in Vienna
in the
1840s
10. The
hospital had two obstetric departments,
and women were admitted alternately,
whatever their clinical
condition, to one or the other. In the first, they
were attended
by medical students who moved straight from the necropsy room
to
the delivery suite. In the second, they were attended by
midwives and
midwifery students who had no contact with the
necropsy room. The incidence of
maternal death was as high as
18% in the first department, with puerperal
fever the main cause,
but only 2% in the second. Semmelweis observed that a
colleague
died from an illness similar to puerperal fever after being
accidentally
cut during a necropsy. He concluded that the infecting particles
responsible
for puerperal fever came from cadavers and were transmitted
by
hand to women attended by medical students in the first department.
He
therefore instituted hand disinfection with chlorinated lime
for those leaving
the necropsy room, after which maternal morbidity
in the first department fell
to the levels achieved by the second
department. In terms of experimental
design Semmelweis conducted
more than a pre and postintervention study; he
performed, albeit
inadvertently, a controlled trial. There is also an element
of
cross-over.
Rammelkamp
Just over a century later another key observation was made. In the wake of
the staphylococcal epidemics of the 1950s, Rammelkamp and
co-workers11
demonstrated that direct contact, and not airborne transmission, was the main
mode of transmission of Staphylococcus aureus. They also
demonstrated, in what would now be called a controlled trial, that handwashing
between patient contacts reduced levels of S. aureus acquisition to
the low levels resulting from airborne transmission. Their experimental
setting was a neonatal nursery, chosen because babies are born sterile. One
group of sterile babies was nursed by a dedicated team of nurses. The other
group included index cases with umbilical staphylococcal infection and was
nursed by a separate team. Throughout the study the first group of nurses
routinely washed their hands between patient contacts. The rate of
staphylococcal acquisition was 10%. The second group of nurses washed their
hands for the first 20 days of the 50-day study, during which time S.
aureus acquisition by babies was 14%. In the second half of the study
they washed their hands only when they felt it clinically indicated and
staphylococcal acquisition rose to 43%.
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HANDWASHING: THE EPIC SYSTEMATIC REVIEW 2001
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The need to reduce infection and hospital-acquired antimicrobial
resistance
prompted a systematic review of handwashing by Thames
Valley University as
part of the EPIC
study
12. This
concluded
that there was good evidence that direct patient contact resulted
in
hand contamination by pathogens. For example, 80% of staff
dressing wounds
infected with methicillin-resistant
S. aureus (MRSA) carried the
organism on their hands for up to 3 hours.
Immediate washing with liquid soap
and water virtually eradicates
the
organism
13,14.
An intensive-therapy-unit study showed that
40% of all patient—nurse
interactions resulted in samespecies
transmission of
Klebsiella to
healthcare workers' hands, lasting
up to 150 minutes, even after contact as
slight as touching
a patient's
shoulder
15. A study
of healthcare workers' hands
sampled within half an hour of contact with
patients with
Clostridium difficile infection showed samespecies
contamination on nearly
60% of hands, even after activities as simple as
returning drug
charts to the end of beds. Washing with soap and water
virtually
eradicated the
organism
16.
The EPIC review showed that liquid (even non-medicated) soap and water
effectively decontaminates hands, but that 70% alcohol or an alcohol-based
antiseptic handrub provides the most effective decontamination for a wide
variety of organisms (S. aureus, Pseudomonas aeruginosa, Klebsiella,
rotavirus17,18).
Liquid soap and water, medicated or otherwise, comes into its own where there
is physical soiling of the hands, but takes a full 90 seconds to apply in the
manner recommended by
EPIC12. Alcohol
handrubs take 10-20 seconds to
apply19 and
healthcare workers are thus more likely to
comply8. Indeed,
while rubbing the solution into the hands one can be doing something else
useful such as communicating with the patient. Time constraints have been
identified by EPIC as one of the main barriers to regular handwashing, another
being allergies to antiseptic preparations. Allergies are much less likely to
arise with alcohol-glycerol preparations, which are now recommended by the
Hand Hygiene (formerly Handwashing) Liaison Group for use between patient
contacts20.
The EPIC review provided evidence from trials of various designs in a wide
range of settings—in particular enteric illness and intensive
care—that handwashing reduces infection rates. However, most studies
compare preintervention with postintervention and do not measure handwashing
compliance. Many confounding factors are present such as case-mix, length of
stay, bed occupancy, staffing levels, intensity of workload, antibiotic use,
regional or seasonal changes, and changes in infection control
practice8,12.
Pittet et
al.8, for
example, reporting that an increase in handwashing compliance was accompanied
by a fall in the MRSA-rate, comment that not all this fall could be ascribed
to improved hand-hygiene; an intensive MRSA isolation programme was introduced
at the same time21.
The Hand Hygiene Liaison Group has identified nine controlled
studies—three randomized control trials, five controlled trials and one
multiple crossover trial—where handwashing compliance was measured by
direct
observation22,23
of use of water, soap,
etc.,24,25,26
or enforced by study investigators in a wide variety of settings
(Table
1)10,11,27,28.
These all show significant reductions in infection-related outcomes, whether
in settings with a high infection rate in critically ill
patients10,24
or in relatively healthy populations with low rates of
infection25,28.
The treatment effect is so great that if ‘hand-hygiene’ were a new
drug it would be used by all. So why is it not ‘used’ by
doctors?
View this table:
[in this window]
[in a new window]
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Table 1. Outcome of randomized (RCT) or other controlled trials (CT) where
handwashing has been directly observed or enforced, or consumables have been
measured
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DOCTORS, MEDICAL STUDENTS AND HAND-HYGIENE
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The Hand Hygiene Liaison Group and the Department of Health
issued
guidance
5,6
stating that handwashing reflects attitudes,
behaviours and beliefs. The
influence of role models may be
critical and the Liaison Group calls for
teaching of elementary
hygiene practice at medical
school
5. Semmelweis'
original work
focused on medical students, but since then handwashing
behaviour
of students has not been reported. We decided to study this
in the
final year MB BS objective structured clinical examination
(OSCE)
9,
because the
OSCE assesses learned attitudes and behaviour absorbed
from role models.
Nearly 200 candidates were assessed during
neurological examination of the
lower limbs, a task that provides
ample opportunity for patient contact
(sweaty feet, groins and
so on). On the first day students were observed to
see whether
they asked to use or used the handrub solution provided. 8%
did
so. On the second day, large signs requesting that they
wash their hands were
available at that station. Nearly 20%
then did so. This year we performed an
identical study with
first-year clinical medical students at their end-of-year
medical
OSCE, and observed a similar compliance rate (Hunt D, personal
communication).
A handwashing questionnaire was administered this time, to
test
knowledge and attitudes. About three-quarters of the students
believed
that they washed their hands at least 60% of the time.
Nearly all believed
that handwashing reduced infection rates,
but only two-thirds thought it might
reduce infective diarrhoea
or antimicrobial resistance.
We concluded from our original
study9 that
handwashing should become an education priority. Since assessment is the
‘tail that wags the dog’, marks for hygiene should be incorporated
into all undergraduate clinical assessment and into teaching quality
assessment. EPIC12
asked for trials of behavioural and educational interventions to improve
handwashing compliance, reiterating calls made by the Hand Hygiene Liaison
Group5,6.
Part of any educational intervention with medical students should be
presentation of the very clear evidence that healthcare workers' hands become
contaminated by pathogens after patient contact, that alcohol handrubs are the
easiest and most effective means of decontaminating hands between patient
contacts and that controlled trial evidence shows that hand-decontamination
substantially reduces infection in many clinical settings. Hand hygiene is the
practice of evidence-based medicine. Medical school curricula should now treat
it thus and should study the efficacy of educational programmes to improve
hand hygiene.
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INTRODUCTION
BACKGROUND
