Spend any time in a hospital and you get the impression medical staff are scrupulous, even obsessive, about cleaning their hands.
At every turn, doctors and nurses seem to be squirting out hand rub, carefully peeling off gloves and gowns, scrubbing hands between patients, and otherwise following the practices shown in those “Clean Hands Save Lives!” posters.
Except . . . they’re not.
Compliance with hand hygiene protocols remains “abysmally low,” according to the World Health Organization. Study after study shows health care workers don’t use enough hand rub, don’t clean the back of their hands, or don’t rub long enough. They leave their wrists exposed or touch dispensers with their fingers; they attempt to disinfect wet hands or improperly remove gloves.
In fact, 76% of healthcare workers miss at least one key moment among WHO’s “Five Moments for Hand Hygiene,” a European research team found.
And according to Swiss researchers, the hands of doctors and nurses deposit – and likely transmit – potentially harmful microbes every 4 seconds onto patients and hospital surfaces.
Stellar hand hygiene is the single most effective way to control hospital-acquired infections — a global crisis fueled by the rise of antibiotic-resistant “superbugs.” Yet even at the most advanced, resource-rich hospitals, WHO reports, compliance is often “well below 40%” and can be “as low as zero per cent.”
There is plenty hospitals can do to improve hand hygiene. But are these measures enough to halt the infection epidemic? Or do hospitals need a new approach?
Why Hand Hygiene Compliance is So Dismal
It’s not that hospitals have dropped the ball on promoting hand hygiene — quite the opposite. Around the globe, they’ve employed all manner of creative videos, posters, stickers, slogans, rewards, and voice prompts.
A Brazilian hospital even aired catchy musical parodies over the in-house radio. American hospitals have dangled ski passes and $300 gas cards for top-notch compliance. Scotland’s national health service has included reminders in staff pay slips, promoting Scotland’s “requirement of a zero tolerance approach to non-compliance with hand hygiene.”[i]
There’s just one problem with the motivational approach, says Ojan Assadian, M.D., president of the Austrian Society for Infection Control: “Realistically, it does not work.”
Reasons abound. Some healthcare workers are too distracted to follow protocol. Others avoid hand rub because they perceive it as drying and irritating. Many believe, falsely, that gloves provide sufficient protection.
In fact, hand-hygiene compliance tends to be worse when gloves are worn than when they aren’t.
For example, a British study titled “The Dirty Hand in the Latex Glove” found hand hygiene compliance among doctors was 41% when they wore gloves — and 50% when they didn’t. A German-Ukranian team found more than 60% of healthcare workers failed to disinfect their hands before putting on gloves, and 80% disregarded hand disinfection upon taking gloves off.
But zooming out, there’s another reason for low compliance: nurses and doctors are human beings. And like all humans, they engage in automatic, unconscious behaviours.
“People often are unaware of what exactly their hands do while they are focused on the main task goal,” Swiss researchers noted in a study of doctors and nurses in ICUs.
Even when healthcare workers know they’re being observed, compliance is sub-par.
In the Swiss study, the researchers outfitted nurses and doctors with head-mounted cameras during morning rounds; the subjects knew their every move would be scrutinized, and with greater accuracy than human observers can achieve. “We could show for the first time in a fast-paced, real clinical setting how frequently healthcare workers’ hands touch surfaces,” the researchers wrote.
Among their findings: hand hygiene compliance ranged from 1% to 5%. The doctors and nurses sustained hand rubbing for a median of 11 seconds, far short of the recommended 20 to 30 seconds.
Pathogens Have Staying Power
Pathogens spread more easily than healthcare workers may realize, yet another reason nurses and doctors don’t fully comply with hygiene protocol.
The reality is, dangerous microbes can proliferate even on intact skin — on the chest and back, in the armpit, and around the perineum — and have “an impressive ability to survive on the hands, sometimes for hours,” as WHO notes. Healthcare workers’ hands can become contaminated even after seemingly “clean” procedures like taking a pulse or a temperature or touching a patient’s groin.
Of course, the contamination risk skyrockets when staff change wound dressings, handle a ventilator, or otherwise come in contact with blood, body fluids, or mucous membranes. In a French study, 24% of healthcare workers’ hands were contaminated with Clostridium difficile spores after routine care of patients infected with the bacteria.
It’s also easy for healthcare workers to contaminate their skin or clothing when they remove protective gear. In a Cleveland, Ohio, study, healthcare workers donned their gloves and gowns in their usual manner, rubbed fluorescent lotion between their hands to simulate dirtied gloves, and then smeared the gloves over their chest and abdomen.
After glove removal, black light showed a “contamination” rate of 52.9% on the workers’ skin and clothing.
Boosting Hand Hygiene Compliance: What Actually Works
In the superbug era, hospitals must take every possible step to improve hand hygiene compliance. The most effective strategies are often the simplest, as demonstrated by the Hand Hygiene Project, an initiative of the Joint Commission Center for Transforming Healthcare.
One hospital boosted compliance by painting the walls to make dispensers more visible. Another marked the threshold of patient rooms with red lines that say, “Wash or don’t cross.”
Many hospitals now use dispensers that squirt precisely the right quantity of rub. Some have added dispensers inside and outside every patient room, alongside shelves that personnel can use to easily put down linens or medications while they disinfect hands.
“If you don’t make it convenient right there at that second, no one is going to go around the corner and wash their hands,” notes the chief medical officer of a Texas hospital.
A Michigan health system has gotten a lot of mileage from a CDC poster showing just how long bacteria can survive on surfaces workers touch every day. “The survival data was earth-shattering for staff,” says the director of infection prevention. “The environment can look clean but have significant concentrations of bacteria.”
The Limits of Hand Hygiene
All these measures can make a difference, but hospitals still must face reality. “In our era of budget cuts and reduced healthcare staffing,” Prof. Assadian asserts, “maintaining perfect compliance may not be feasible.”
But here’s the thing: even perfect compliance would not stop the spread of pathogens via healthcare workers’ hands. In the Ohio glove-and-gown-removal study, skin and clothing were contaminated 30 per cent of the time even when proper technique was followed.
Fact is, infections are often transmitted in ways that bypass healthcare workers’ hands.
Bacteria can be launched airborne by the sneeze, the cough, or even the breath of a sick patient and then waft through the hospital, landing on a vulnerable patient’s bed rail or food tray. Pathogens can venture into the hospital lobby from the outdoors, travel via air currents down the hallway, and settle on a patient’s wheelchair or IV pole.
Even the movement of staff, visitors, access doors, and privacy curtains can influence air currents, dispersing pathogen-bearing particles throughout the hospital with no help from a nurse’s or doctor’s hands.
It is critical, then, for hospitals to raise standards for disinfecting hospital surfaces, including sinks, toilet handles, light switches, bed rails, and door knobs.
Hospitals must also use advanced technology to disinfect the air — not just in patient rooms and operating theatres, but also in emergency entrances, lobbies, corridors, stairwells, and cafeterias. In the superbug era, HEPA filters will no longer suffice; the current crisis demands plasma technology, ensuring pathogens will be killed on contact.
For two decades, Dr. Assadian notes, infection-control experts have focused their efforts on improving hand hygiene. But these efforts, research demonstrates, are inherently limited.
“It is time,” he says, “to rethink our approach and combine existing strategies with new technology.”