Clean hands save lives


Hand hygiene is important. We all know that. But its practice remains capricious even in healthcare centres. Now hospitals are taking active measures to improve.

IT WAS a busy day in the outpatient emergency department – one of those days where patients needing drips, oxygen or sutures filed in by the dozens.

As the medical officer’s tired eyes scanned yet another request for an intravenous (IV) drip for a mildly dehydrated young girl, he reached into the storage cabinet with gloved hands for the drip set.

He then ushered the girl to an armchair and comforted her as he uncapped the drip needle. With swift, practised moves, he swabbed the puncture site with alcohol and the needle was painlessly inserted into a vein in the girl’s arm.

Satisfied, he moved on to the next patient.

He has done everything right: he responded immediately to the request, he made an effort to comfort the patient and administered the drip with the least pain possible.

Now, here’s a trick question: Could the medical officer have done better?

Actually, he could have – as you will find out if you have read the guidelines for hand hygiene by the WHO, US Centers for Disease Control and Prevention (CDC) or the UK National Patient Safety Agency.

For starters, he could have changed into a new pair of gloves before touching every patient. And, it would be better if he also washed his hands before and after each encounter (even if you wear gloves, you still need to clean your hands).

These may be little details, but studies have proved that the diligent practice of proper hand hygiene can reduce hospital-acquired infections (HAI) – infections that prolong patients’ stays in the hospital and make them sicker.

“Despite all the campaigns, hand hygiene compliance (among healthcare workers) used to be only 40 to 50% at best worldwide, but now we could reach about 60 to 70% with alcohol based hand-rubs,” says Dr Christopher Lee, an infectious diseases unit head of a government hospital.

To achieve better hand hygiene, hospitals are stepping up efforts to improve their hand hygiene compliance. Not only could it save operational costs incurred by longer hospital stays, it could, very well, save patients’ lives.

The ideals and the reality

Ideally, this is what a healthcare worker (doctor, nurses or supporting staff) should do when he or she examines you in a clinic or in a hospital ward, according to the WHO in their educational poster, My Five Moments for Hand Hygiene.

They should clean their hands:

1. Before touching you.

2. Immediately before aseptic tasks (tasks that are supposed to be performed under sterile conditions, eg oral/dental care, catheter insertion, preparation of medications and food).

3. Immediately after an exposure risk to bodily fluids (the handling of bodily fluids, touching or cleaning a surface exposed to bodily fluids).

4. After touching a patient or his immediate surroundings, when leaving the patient’s side.

5. After touching an object or furniture in a patient’s immediate surroundings, even if the patient has not been touched.

As for how they should clean their hands, the World Alliance on Patient Safety recommends hand-washing only when the hands are visibly soiled, and the use of alcohol-based hand rubs if they are not.

To effectively wash hands with soap and water will take roughly 20 seconds (the time you need to sing “Happy Birthday” twice). Decontaminating hands effectively with an alcohol-based hand rub will only take about 40 to 60 seconds.

It should be easy to follow, provided that the healthcare worker is not in a rush, has an alcohol-based hand rub within his/her reach and is not tired or overworked.

As Irene Quah, director of nursing at a private hospital put it, “there are challenges, as we are still human.”

In fact, the CDC also included a summary of challenges put forth in Didier Pittet’s review article, Improving Compliance with Hand Hygiene in Hospitals, in their guideline for hand hygiene in healthcare settings.

The report listed the perceived barriers to appropriate hand hygiene reported by healthcare workers in the US, some of them assessed and even quantified in observational studies.

According to the workers, the main reasons for poor compliance with hand hygiene are:

·Skin irritation caused by hand hygiene agents

·Inaccessible hand hygiene supplies

·Interference of healthcare worker-patient relationship

·“Patient needs take priority”

·The wearing of gloves

·Not thinking about it or forgetfulness

·Lack of knowledge of guidelines

·Lack of scientific information on effect of hand hygiene on nosocomial (hospital-acquired) infection rates

·Too busy or insufficient time for hand hygiene

·High workload or lack of appropriate staffing

·Being a physician or nurse assistant (rather than a nurse)

·Male (rather than female) gender

·Working in high-risk areas (eg ICUs)

·Lack of role models for hand hygiene

·Lack of administrative sanction of non-compliers or rewarding of compliers

Only about six of these self-reported reasons were assessed and confirmed in observational studies, but it provides valuable insight on the reasons why healthcare workers aren’t cleaning their hands enough.

Back home, Quah lists the inaccessibility of hand hygiene facilities, skin irritation caused by hand hygiene agents and the tendency to overlook hand hygiene during busy days as the challenges most prevalent in her hospital.

“In the past, hand hygiene was synonymous with hand washing, but to move back and forth between sinks is inconvenient and sometimes difficult to practise,” she says.

Although alcohol-based hand rubs (rinses, gels and foams) were already commercially available for many years, they were not well received back then mainly because they can make healthcare workers’ hands dry.

“Now, with emollients added to hand rubs, healthcare workers find them kinder on the hands and easier to use,” says Quah.

“There is a change in the way we practise hand hygiene. Now, we use alcohol hand rubs when our hands are not visibly soiled and wash our hands with soap and water when they are.

“Besides, hand washing is also needed when we are about to perform invasive procedures,” she adds.

With new products and trends in hand hygiene practices coming to the fore, hospital staff need to be re-educated on hand hygiene in order to reinforce their awareness and encourage their compliance to new hygiene standards, she notes.

Improving hand hygiene

While cleaning your hands appropriately may be trying in stressful times, is not impossible. Those 20-60 seconds may be well worth it if you could prevent a fatal hospital-acquired infection or one that could result in a patient spending three more days in the ward.

Meeting the challenges will take time, says Quah, but progress has been made. To reinforce good hygiene practices, local hospital infection control committees are launching awareness campaigns, performing audits and supplying their staff with adequate tools to clean their hands.

Besides holding campaigns, some government hospitals have already placed alcohol hand rubs in their wards and corridors to encourage their use. One even hands out small bottles of alcohol hand rubs to its clinical staff so they have one at hand should the need for it arise.

Infection control manager Trudy Khoo, who works with Quah on the infection control committee in their hospital, speaks of her experience. In their ongoing hand hygiene campaign which started in August 2007, she was given the task of training the hospital staff on good hand hygiene practices.

“It is our aim to train everyone working in the hospital on the best infection control practices, and hand hygiene is one of the most important practices we teach,” says Khoo. “Now, about 90% of our staff have gone for the training.”

To assess compliance, bottles of alcohol hand rubs placed strategically outside patient rooms and nurse counters in the wards are routinely checked by infection control committee members to monitor their use.

What next?

Encouraging good hand hygiene practices among healthcare workers is a good start, but more should be done to educate the public about keeping their hands clean when they are in a healthcare centre – be it a hospital, clinic or a dentist’s office.

“As visitors can also bring in bacteria from outside the hospital, they should also practise good hand hygiene too,” says Quah. Patients could also play their part in making sure their visitors and those who care for them clean their hands before and after touching them.

“We are changing our approach to one that allows patients to also take responsibility for his/her care. Who else would be in a better position to ask a visitor or a healthcare worker to wash their hands?” notes Quah.

“We have posters about patient’s rights and responsibilities and hand hygiene up around the hospital, so patients are informed,” says Khoo. “We also wear badges that say ‘ask me whether I have washed my hands’.”

However, as Asians tend to be more reserved, some may find it difficult to voice their concerns directly. At times, adopting this approach might also be seen as shifting the responsibility of ensuring good hand hygiene practices to patients.

“Patients may think, ‘why do I have to remind my nurses to wash their hands when they ought to in the first place?’” Quah explains.

That is why patient education is important, and hopefully with time we will be able to encourage patients to speak up, she adds.

To find out more about hand hygiene in a healthcare setting, visit the WHO website on their Save Lives: Clean Your Hands initiative at This article is in collaboration with B. Braun.

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