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Listen to the Experts
CDC Special Issue Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach Didier Pittet University of Geneva Hospitals, Geneva, Switzerland
Hand hygiene prevents cross-infection in hospitals, but health-care workers' adherence to guidelines is poor. Easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcohol-based hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating, and contribute to sustained improvement in compliance associated with decreased infection rates. This article reviews barriers to appropriate hand hygiene and risk factors for noncompliance and proposes strategies for promoting hand hygiene. Definitions Two major groups of microorganisms are found on the skin: organisms that normally reside on it (resident flora) and contaminants (transient flora). Unless introduced into body tissues by trauma or medical devices such as intravenous catheters, the pathogenic potential of the resident flora is low. Transient flora, which are easily removed by handwashing, cause most hospital infections resulting from cross-transmission. The term hand hygiene includes several actions intended to decrease colonization with transient flora. This objective can be achieved through handwashing or hand disinfection. Handwashing refers to washing hands with an unmedicated detergent and water or water alone. Its objective is to prevent cross-transmission by removing dirt and loose transient flora. Hygienic handwash refers to the same procedure when an antiseptic agent is added to the detergent. Hand disinfection refers to use of an antiseptic solution to clean hands, either medicated soap or alcohol. Some experts refer to the action of "degerming" as the use of detergent-based antiseptics or alcohol. Hygienic hand rub is rubbing hands with a small quantity (2 mL to 3 mL) of a highly effective, fast-acting antiseptic agent. Promotion of hand hygiene is a major challenge for infection control experts. In-service education, distribution of information leaflets, workshops and lectures, and performance feedback on compliance rates have been associated with transient improvement. No single intervention has consistently improved compliance with hand hygiene practices. This review summarizes factors influencing lack of adherence by health-care personnel to hand hygiene procedures and suggests strategies for improvement. Hand Hygiene Agents If hands are known to be or suspected of being contaminated, transient flora must be eliminated by washing or disinfecting the hands to render them safe for the next patient contact. Plain soap with water can physically remove a certain level of microbes, but antiseptic agents are necessary to kill microorganisms. Hand antiseptic agents are designed to rapidly eliminate most transient flora by their mechanical detergent effect and to exert an additional sustained antimicrobial activity on remaining flora. The multiplication of resident flora may be retarded as well, so that hand disinfection may be useful in situations in which microbiologically clean hands are required for extended periods. Rotter showed that hand hygiene with unmedicated soap and water removed some transient flora mechanically; preparations containing antiseptic or antimicrobial agents not only removed flora mechanically but also chemically killed contaminating and colonizing flora, with long-term residual activity. Alcohol-based preparations have more rapid action than products containing other antiseptics (e.g., chlorhexidine gluconate or providone iodine). Semmelweis observed that normal handwashing did not always prevent the spread of fatal infection and recommended hand disinfection in a solution of chlorinated water before each vaginal examination. Hand disinfection is substantially more efficient than standard handwashing with soap and water or water alone, particularly when contamination is heavy. Frequent handwashing may result in minimal reduction or even an increase in bacterial yield over baseline counts of clean hands. Because alcohols have excellent activity and the most rapid bactericidal action of all antiseptics, they are the preferred agents for hygienic hand rubs, so-called "waterless hand disinfection." In addition, alcohols are more convenient than aqueous solutions for hygienic hand rubs because of their excellent spreading quality and rapid evaporation. At equal concentrations, n-propanol is the most effective alcohol and ethanol the least. Alcohol-based hand rubs are well suited for hygienic hand disinfection for the following reasons: optimal antimicrobial spectrum (active against all bacteria and most clinically important viruses, yeasts, and fungi); no wash basin necessary for use and easy availability at bedside; no microbial contamination of health-care workers' clothing; and rapidity of action. After extensive reduction following hand disinfection with an alcohol preparation, it takes the resident skin flora several hours to become completely restored. Since alcohol alone has no lasting effect, another compound with antiseptic activity may be added to the disinfection solution to prolong the effect. These antiseptics have recently been extensively reviewed by Rotter. Prevention of bacterial contamination and subsequent infection requires timely hand cleansing. Guidelines have delineated indications for hand cleansing but without reliance on evidence-based studies of microbiologic contamination acquired during routine patient care. To provide such evidence, we studied the dynamics of bacterial contamination of health-care workers' hands in daily hospital practice. Our findings should help identify patient-care situations associated with high contamination levels and improve hand cleansing practices. Structured observations of patient care were conducted by trained external observers, who took an imprint of the fingertips of the health-care worker's dominant hand to quantify bacterial colony counts at the end of a defined period of patient care. Bacterial contamination on ungloved hands increased linearly during patient care (mean 16 CFU per minute, 95% confidence interval [CI]. Activities independently associated with higher contamination levels were direct patient contact, respiratory care, handling body fluids, and disruption in the sequence of patient care (all p 49 CFU, p = 0.03). Both the duration and type of patient care influenced hand contamination. Furthermore, simple handwashing before patient care, without hand disinfection, was also associated with higher colony counts (>52 CFU, p = 0.03), which suggests that hand antisepsis is better than standard handwashing. These findings suggested that intervention trials should explore the role of systematic hand disinfection as a cornerstone of infection control to reduce cross-transmission in hospitals. |
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