Hand Hygiene: A Frequently Missed Lifesaving Opportunity During Patient Care
Excerpts of an article by Dr. Andrej Trampuz and Dr. Andreas F. Widmer

Nosocomial infections affect nearly 10 per cent of hospitalized patients and represent a major problem in health care facilities, resulting in prolonged hospital stays, substantial morbidity and mortality and excessive costs. In the United States, health care associated infections contribute to the deaths of nearly 90,000 hospital patients each year and increase annual medical expenses by approximately $4.5 billion.

In addition, multi-drug-resistant pathogens are commonly involved in such infections and render effective treatment challenging. The hands of healthcare workers are the primary mode of transmission of multi-drug-drug-resistant pathogens and infections to patients. Proper hand hygiene is the single most important, simplest, and least expensive means of preventing healthcare associated infections and the spread of antimicrobial resistance. Nevertheless, in most healthcare institutions, adherence to recommended handwashing practices remains unacceptably low, rarely exceeding 40 per cent of situations in which hand hygiene is indicated.

Why do healthcare workers consistently fail to perform this simple and inexpensive procedure, thereby compromising patient safety and the quality of medical care? The reasons for poor hand hygiene practices include lack of scientific knowledge, unawareness of risks, misconceptions (eg. Glove use obviates the need for hand hygiene), unavailability of hand hygiene facilities (sinks or alcohol dispensers), lack of role models among colleagues or superiors, understaffing or patient overcrowding, and lack of institutional priority.

MICROBIAL SKIN FLORA
Normal human skin harbours bacteria, usually between 100 and 1,000,000 CFU per square centimetre. During daily activity, healthcare workers’ progressively accumulate microorganisms on their hands from direct patient contact or contact with contaminated environmental surfaces and devices. Traditionally, microorganisms residing on the hands are divided into “resident” and “transient” flora.

Resident flora colonizes deeper skin layers and is more resistant to mechanical removal than transient flora. These bacteria multiply in hair follicles and remain relatively stable over time. Resident flora generally has lower pathogenic potential than transient flora and is considered important for colonization resistance, preventing colonization with other, potentially more pathogenic, microorganisms.

Transient flora colonizes the superficial skin layers for short periods and is usually acquired by contact with a patient or contaminated environment. These microorganisms are easily removed by mechanical means such as hand washing. Transient flora is responsible for most healthcare associated infections and the spread of antimicrobial resistance.

TWO BASIC CONCEPTS OF HAND HYGIENE
Two fundamentally different hand hygiene concepts exist – hand washing and hand rubbing. Hand washing refers to the application of a plain (non-antimicrobial) or antiseptic (antimicrobial) soap, mechanical friction generated by rubbing the hands together, rinsing and drying. The cleaning activity is attributed to detergent properties, which result in the mechanical removal of dirt and loosely adherent flora from the hands. The second concept, hand rubbing, involves the use of alcohol rather than water. In contrast to hand washing, the objective of this procedure is a more effective and rapid reduction of skin flora by killing, not mechanically removing, microorganisms (all transient flora and most resident flora). Therefore the alcohol hand rub procedure should not be confused with hand washing. The antimicrobial activity of alcohols is based on protein denaturation. They have excellent and rapid (within seconds) germicidal activity.

EDUCATION AND MOTIVATION OF HEALTHCARE WORKERS
Switching from hand washing to an alcohol hand rub procedure requires a system and behavioural change in healthcare institutions. Strategies to improve hand hygiene adherence must be multifaceted and include the education and motivation of healthcare workers, the use of performance indicators and hospital management support. Writing new hand hygiene guidelines alone is not enough. Simple training sessions for healthcare workers should be held on each ward to introduce the advantages of alcohol hand rubs over had washing. In addition, patients can be educated about the importance of hand hygiene and be encouraged to ask healthcare workers to comply with hand hygiene guidelines. The efficiency of the hand rub technique can be evaluated with an alcohol product supplemented with fluorescent dye and an ultraviolet light. Another way to estimate the quality of hand hygiene is to evaluate the consumption of soap and alcohol. If healthcare workers strictly follow the Centres for Disease Control and Prevention hand hygiene recommendations, the ratio between soap and alcohol consumption should be close to 1:10. In order to improve patient safety and reduce costs, good hand hygiene should become one of the highest priorities in healthcare institutions.

CONCLUSION
The hands of healthcare workers are the most common mode of transmission of pathogens to patients. Proper hand hygiene can prevent healthcare associated infections and the spread of antimicrobial resistance. The alcohol hand rub technique is microbiologically more effective, more accessible and less likely to cause skin problems, and saves time and human resources. As a consequence, alcohol hand rubs are associated with substantially better adherence to hand hygiene than hand washing. The use of alcohol-based hand rubs should replace hand washing as the standard for hand hygiene in healthcare settings in all situations in which the hands are not visibly soiled.