Hand hygiene is the first and most important shield against infection. In this article Dr Alexandropoulou looks at what can be done to improve hand hygiene both in hospitals and the wider community.
Hand hygiene: A history
Our hands are the main mode of transmission for microorganisms. Noticing this fact in 1847, Ignaz Semmelweis established specific antiseptic policies for hand hygiene where he worked in the obstetrics clinic of the General Hospital of Vienna, drastically reducing postpartum deaths from puerperal fever.
Many years later, Florence Nightingale necessitated the use of hard brushes in hand cleaning and established the known public health standards in battlefield hospitals. She did so after the observation that more soldiers died from infections than injuries.
Since the time of Semmelweis, the introduction of many new products and the proposal of alternative methods for proper hand hygiene have increased our attention in this good practise and its benefits. Nevertheless, there is still a challenge to public health: hospitals’ infection prevention committees and administrations must improve staff compliance with the instructions given and proposed by national and international scientific institutions.
The simplest and most important step in preventing infections associated with public health services is hand hygiene. It is estimated that these infections affect 1.4 million patients worldwide. In Europe every year five million patients acquire nosocomial infections, attributing to 50,000 deaths.
In 2007, the results of a study by an American link of microbiologists showed that after using a public toilet only 66% of men and 88% of women were observed to wash their hands.
An explosion of hospital acquired infections (HAIs) has been noted in recent years, and Greece holds one of the worst records in Europe, with the biggest problems being observed in intensive care units (ICU). According to some infectious diseases professionals, between 20% and 30% of nosocomial infections can be prevented by establishing simple measures such as hand hygiene and the proper management of patients infected by multidrug resistant pathogens.
The problem of nosocomial infections presents a major threat in every country, as severe disease and even mortality are attributable to infections from multidrug resistant pathogens.
Microorganisms: universal habitants
Microorganisms are everywhere. In the environment around us we have found microbes in temperatures ranging from boiling to below freezing, in the dirt and soil through to the upper layers of the atmosphere and even in the deepest oceans and acidic lakes with high hydrostatic pressures.
Microbes can survive in extreme environmental conditions due to their durable structure, as can highly resistant bacterial spores, cysts and protozoa and ova spores.
The majority of microbes present in the environment are friendly to humans and some are also part of the resident microflora of our bodies. Nevertheless, there are a number of microbes that can cause disease in humans. Some of these pathogens can be transmitted from everyday objects to us through the hands because of reduced or improper hygiene.
Microflora: resident or transient
As we mentioned previously, many microorganisms are harmless to people. In the case of the hands, resident flora includes microorganisms such as coagulase negative Staphylococcus aureus, Corynebacterium spp, Propionibacterium spp, Acinetobacter spp and Enterobacteriaceae.
In contrast with these harmless bacteria, transient flora is responsible for the majority of infections and foodborne diseases, including microorganisms such as E coli, Salmonella spp, Shigella spp, Clostridium perfringens, Giardia lambia, Cryptosporidium parvum, Norwalk virus, and Hepatitis Avirus.
The main routes of acquisition of these microorganisms are the use of toilets, contact with raw food, contact with contaminated food, contact with sick people, and sneezing in the hands.
Achieving hand hygiene
Hand hygiene is achieved through hand washing, antiseptic or surgical hand antisepsis. Hand washing is achieved with soap and water, or antibacterial soap and water.
Hand antisepsis is applied as dry washing with an alcohol solution or alcohol based hand rub. In the case of healthcare professionals, it should be applied before and after each contact with the patient. If hands are visibly soiled with dirt or organic materials, they should be washed prior to this with soap and water.
Surgical hand antisepsis, which includes antiseptic hand washing or rubbing the hands with anhydrous antiseptic formulation, is followed pre-operatively by the surgical group.
Washing with soap and water mechanically removes impurities, organic substances and transient flora. It is considered satisfactory when used by the general population and food handlers. Hand antisepsis with an alcohol formulation leads to the destruction of transient flora and is the first choice for healthcare professionals. It is not, however, recommended to food handlers, as the alcohol can be inactivated by organic matter. Dry washing can be used after simple washing with soap and water. Surgical hand antisepsis leads to the removal of transient bacteria and minimises the permanent microbial flora of the hands.
Transmission of HAIs
The reduction of HAIs is of utmost importance to patient safety, especially when considering that most infections can be avoided. Any initiative taken to support increased personal hygiene should be recognised and promoted. In healthcare facilities the main mode of infection transmission is person to person, while transmission in food companies generally follows the faecal-oral route. Microbes are then transferred from patients into the hands of healthcare professionals. Once there, microbes proliferate and are transferred from one patient to another.
This route of infection takes place only via the contaminated hands of health professionals and has been repeatedly associated with increased incidence of nosocomial infections. It has also been demonstrated by studies that increased compliance with the appropriate hand hygiene practises leads to a reduction in the incidence of these infections.
Acknowledging this fact, the World Health Organization (WHO) raised the issue of proper hand hygiene as a top priority, declaring that: “Clean care is safer care” (WHO, First Global Patient Safety Challenge).
The WHO’s Five Moments for Hand Hygiene define the space and time where hand hygiene must be applied:
- Pior to contact with the patient
- Before every clean or sterile handling
- After exposure or risk of exposure to body fluids of the patient
- Upon contact with the patient
- After the contact with the patient’s immediate environment
The proper observance of hand hygiene rules continues to be one of the key points of all nosocomial infection prevention programmes. This leads to the saying that the top ten causes of nosocomial infections are the ten digits of our hands.
Hand hygiene in hospitals and the community
Hand hygiene should be applied not only in the field of health, but also by food handlers and the general population. The promotion of hand hygiene reduces infection of any kind, including gastrointestinal and respiratory infection. This is especially important for children, as it appears that adults’ hand hygiene largely protects them from microorganisms. In addition, studies have shown that 50% of students probably do not wash their hands after using the toilet, putting everyone else at risk each day.
Use of gloves
The use of gloves does not replace, in any circumstance, the need for hand hygiene. Gloves are required before any aseptic handling, when there is contact with blood, body fluids, mucous membranes or skin infections, during the removal of contamination when cleaning contaminated surfaces, and when required to implement special precautions to the patient.
Gloves should be removed:
- After contact with one patient and before caring for the next
- After contact with an infected area and before touching the next area – infected or not
- When they are torn or infected
Hands should always be washed both before donning and after removing gloves.
It should be noted, however, that the use of gloves should not be abused. The environment inside gloves is ideal for microbial growth, especially when gloves are worn on unwashed hands.
Successful hand hygiene awareness
The main challenge in achieving hand hygiene is to understand its importance in the inhibition of microbial dispersion, thereby reducing infections. The provision of appropriate tools by the hospital or employer for maintaining hand hygiene should be raised. Adequate knowledge of the WHO’s Five Moments for Hand Hygiene and the application of good hygiene techniques should be promoted.
Hand hygiene should be followed by all staff before and after contact with patients or food. The challenge to all healthcare professionals and employees is to exercise adequate hand hygiene. Furthermore, in the case of healthcare facilities, visitors should be encouraged to do the same.
To make hand hygiene even easier for all, an antiseptic solution should exist in every corner of the hospital.
It is not enough to tell someone to wash his/her hands, you must also explain the proper technique and when it should be used. Hand hygiene awareness should be taught from preschool age. Hand washing is a very important issue and its promotion in school can be done with appropriate educational programmes, including lessons about the microorganisms and their transmission.
Many international organisations have established guidelines and recommendations on this crucial public health issue. WHO has established guidelines recommending that all healthcare professionals should wash their hands with soap and water when they are visibly soiled with blood or other biological fluid, or after any suspected or confirmed exposure to pathogens. In all other cases hand hygiene with an alcohol antiseptic solution at the point of patient care is the best option because it is faster, more effective and better tolerated by the skin.
Annually, May 5 has been designated by WHO as a day dedicated to hand hygiene. Efforts are focused on the widest possible awareness and compliance with the principles and guidelines for proper hand hygiene, not only for healthcare professionals, but also for the public, with the aim of protecting the health and safety of patients in healthcare facilities.
Another global organisation is the Public Private Partnership for Hand Washing (PPPHW), which aims to prevent diarrhoea by establishing practises for proper hand washing with soap. According to this organisation, diarrhoea kills more than two million children each year.
The major source of most pathogens that cause diarrhoea is human excrement, therefore proper hand hygiene could support public health improvement. A recent review of all available evidence suggests that the use of soap could reduce the incidence of diarrhoea by 47 % and could save at least a million lives.
With the support of PPPHW, The United Nations Children’s Fund (UNISEF) and other organisations set October 15 as Global Handwashing Day. The day’s vision is to raise global awareness of this practise.
Even though people all around the world wash their hands, there are too few who use soap and water and follow the proper techniques for hand hygiene after critical cases.
If hand hygiene remains random and unclear then it will be an ongoing risk of infection. Hand hygiene interventions aim to ensure the safety of patients and professionals in hospitals, as well as the general population outside healthcare facilities.
Hand hygiene concerns us all. Whether achieved through washing or antisepsis, it remains the most important measure to prevent nosocomial infections.