Hand washing -- Handwashing Liaison Group 318 (7185): = 686 -- BMJ

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Home > Comment > BMJ=20 1999;318(7185):686 (13 March), doi:

BMJ 1999;318:686-686 = ( 13 March )

Editorials

Hand washing

A modest measure $3D---=20$ with=20 big effects

Hospital acquired infection damages patients, prolongs hospital = stays,=20 consumes scarce hospital resources, and thus presentsa major = challenge for clinical governance.^{1=20
In a seminal interventionstudy 150 years ago Semmelweis =

insisted that doctors performingnecropsies washed their =
hands before=20
delivering babies, so reducingmortality due to streptococcal =

puerperal sepsis from 22% to 3%.^{2⁼²⁰Many studies since have confirmed that doctors =
decontaminating⁼²⁰their hands between seeing patients can reduce hospital =
infection⁼²⁰rates.^{3=20
Nevertheless, healthcare workers still fail to washtheir =
hands and=20
fail to appreciate the importance of doing so.^{3⁼²⁰This month the Department of Health has had another attempt =
at⁼²⁰reminding them by sending a document and health circular to =
all⁼²⁰NHS chief executives, public health directors, and =
microbiologists⁼²⁰inEngland.}}}}

Many observational studies, mainly conducted in intensive care units, = show=20 low rates of hand washing, especially among doctors.^{4⁼²⁰Bartzokas et al observed that, despite frequent patient =
contacts,⁼²⁰senior doctors washed their hands only twice during 21 hours =
of⁼²⁰ward rounds.^{5=20
Though doctors spend less time than nurses indirect patient =
contact=20
and may think that they need to decontaminatetheir hands =
less often,=20
they have many transient contacts andmove from ward to ward. =
The=20
same is true for phlebotomists, physiotherapists,⁼radiographers, and=20
varioustechnicians.}}

Self reporting overestimates compliance. After unobtrusive = observation of=20 doctors to obtain a baseline hand washing rate,Tibballs = asked a=20 sample to estimate their own hand washing ratesbefore = patient=20 contact. Their perceived rate of 73% (range 50%-95%)⁼contrasted=20 sharply with the observed frequency of just 9%.^{6⁼²⁰Pritchard and Raper were astonished that "doctors can be so=20
extraordinarilyself-delusional about their behaviour."⁷⁼²⁰}

Why is compliance so poor? Even when taught the theoretical basis of = hand=20 washing, healthcare workers do not seem to understandthe = risks=20 associated with non-compliance.^{8=20
Hospital acquiredinfections usually present as sporadic =
cases,=20
perceived as insignificantor unrelated to non-compliance. =
Staff=20
horrified by lice on a patientfail to consider the =
potentially far=20
more serious consequencesof bacteria present on their⁼²⁰hands.}

The failure of healthcare workers to decontaminate their hands = reflects=20 fundamentals of attitudes, beliefs, and behaviour,and there = are no=20 simple solutions. Many attempts have been madeto improve = hand=20 washing compliance through education, and indeedelementary = hygiene=20 practice should be taught explicitly in medicalschools. = Principles=20 taught in the lecture theatre can be reinforcedby = experiential=20 learning, such as demonstrating the need for properhand = washing=20 technique by showing microbial growth from unwashedhands^{9=20
and by using fluorescent oil-based dyes to illustratethe=20
effectiveness of hand washing. Such methods increase personal⁼impact,=20
but, though they may be temporarily improve compliance,⁼behavioural=20
changes tend not to bemaintained.}

Role models are important in hospital practice. Junior doctors washed = their=20 hands more often when consultants set an example(although = they were=20 not perfect, washing their hands on fewerthan half the = indicated=20 occasions) (Larson and Larson, conferenceof Association of=20 Practitioners in Infection Control, San Diego,1983). = Unfortunately,=20 poor practice can also be learnt at thebedside. Junior staff = and=20 students taught to wash their handsabandoned the habit when = others,=20 especially more senior ward staff,did not bother.^{10<=
/SUP>=20
Senior staff should take the lead to achievelasting =
behavioural=20
change. To increase compliance, medical staffcould police =
each=20
other,^{11<=
/SUP>=20
and it has even been suggested thatpatients should be =
encouraged to=20
ask their carers to wash theirhands.}}

It is clear that healthcare workers fail to understand the importance = of hand=20 washing. This issue is so crucial that we needa greater = commitment=20 from management to influence their behaviour.It is now time = for an=20 explicit standard to be set, that handsshould be = decontaminated=20 before each patient contact. If sucha policy is not in place = or=20 being followed, the trust concernedmay be liable in the = event of=20 litigation. The culture change requiredfor this new practice = may be=20 forbidding, but similar challengessuch as the safe disposal = of=20 sharps and, in another setting, theuse of seat belts in = cars, have=20 been faced and overcome. Handdecontamination should have = similar=20 status to other health andsafety policies, where individuals = are=20 accountable for day today operational practices. Hand = washing should=20 be regarded aspart of the normal duty ofcare. =
Handwashing Liaison = Group. ^*==20

c/o Louise Teare, Chelmsford Public Health Laboratory, Chelmsford CM2 = 0YX=20 (L.Teare{at}btinternet.com )

Acknowledgments

^* Of the Hospital Infection Society, = Association=20 of Medical Microbiologists, Department of Health, Infection Control = Nurses⁼²⁰Association, Royal College of Nursing, Public Health=20 LaboratoryService: Barry Cookson, Gary French, Dinah Gould,=20 Elizabeth Jenner,J McCulloch, Anne Pallett, M Schwieger, = Geoffrey=20 Scott, JennieWilson.=20

Emmerson AM, Enstone JE, Griffin M. The = second national=20 prevalence survey of infection in hospitals. J Hosp Infection = 1996; 32:=20 175-190[Medline].
Rotter ML. 150 years of hand = disinfection $3D---=20$ Semmelweis' heritage. Hyg Med 1997; 22: 332-339.
Larson EL. APIC Guidelines for handwashing = and hand=20 antisepsis in health care settings. Am J Infection Control = 1995; 23:=20 251-269[Medline].
Gould D. Can ward-based learning improve = infection=20 control? Nursing Times 1996; 92: 42-43[Medline].
Bartzokas CA, Williams EE, Slade PD. A = psychological=20 approach to hospital-acquired infections. In: Studies in health and = human=20 sciences. London: Edward Mellen , 1995.
Tibballs J. Teaching hospital medical staff = to=20 handwash. Med J Austral 1996; 164: 395-398.
Pritchard RC, Raper RF. Doctors and = handwashing:=20 instilling Semmelweis' message. Med J Austral = 1996;164:389-90.
Pritchard V, Hathaway C. Patient = handwashing practice.=20 Nursing Times 1988; 84: 68-72[Medline].
Emmerson AM, Ridgway GL. Teaching asepsis = to medical=20 students. J Hosp Infection 1980; 1: 289-292[Medline].
Larson E, McGinley KJ, Grove GL, Leyden = JJ, Talbot=20 GH. Physiological, microbiologic and seasonal effects of handwashing = on the=20 skin of health care personnel. Am J Infection Control 1986; 14: = 51-59[Medline].
Kaplan LM, McGuckin M. Increasing = handwashing=20 compliance with more accessible sinks. Infection Control 1986; = 7:=20 408-410[Medline].
Jarvis WR. Handwashing: the Semmelweis = lesson=20 forgotten? Lancet 1994; 344: 1311-1312[Medline].=20

=A9 = BMJ=20 1999

GPs can improve their hand washing habits=20: Barbara Michiels, Dirk Avonts, Paul van Royen, and Joke = Denekens
BMJ=20 2000 320: 869. [Extract] [Full = Text]=20

Hand washing=20: Andrew Weeks, Rachel Sen, Maeve Keaney, Ann Trail, Carol Howard, = Paul=20 Chadwick, S Kesavan, C Richard B Welbourn, Steve M Jones, Paul M = Hateley, P A=20 Jurnaa, Robert MacDermott, D Varghese, H Patel, and A Majid = Katme
BMJ 1999=20 319: 518. [Extract] [Full = Text]=20

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Awofeso, N. (2004). What's New About the "New Public Health"?. = Am. J.=20 Public Health 94: 705-709 [Abstract]= [Full text] = =20
Stone, A. (2003). Audit of soap usage by a primary care team. = BMJ=20 327: 1453-1454 [Full = text]=20 =20
Buchan, H (2003). Using research knowledge to improve health care. = Qual Saf Health Care 12: 322-323 [Full = text]=20 =20
Wester, C. W., Durairaj, L., Evans, A. T., Schwartz, D. N., = Husain, S.,=20 Martinez, E. (2002). Antibiotic Resistance: A Survey of Physician = Perceptions.=20 Arch Intern Med 162: 2210-2216 [A= bstract]=20 [Full = text] =20
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Teare, L., Cookson, B., Stone, S. (2001). Hand hygiene. = BMJ 323:=20 411-412 [Full=20 text] =20
Merry, A. F., Miller, T. E., Findon, G., Webster, C. S., Neff, S. = P. W.=20 (2001). Touch contamination levels during anaesthetic procedures and = their=20 relationship to hand hygiene procedures: a clinical audit. Br J=20 Anaesth 87: 291-294 [Abs= tract]=20 [Full=20 text] =20
Stone, S P (2001). Hand hygiene--the case for evidence-based = education.=20 J. R. Soc. Med. 94: 278-281 [Full text] = =20
Saloojee, H, Steenhoff, A (2001). The health professional's role = in=20 preventing nosocomial infections. Postgrad. Med. J. 77: 16-19 = [Abst= ract]=20 [Full=20 text] =20
Farrar, J J, Yen, L M, Cook, T, Fairweather, N, Binh, N, Parry, J, = Parry,=20 C M (2000). NEUROLOGICAL ASPECTS OF TROPICAL DISEASE: Tetanus. J. = Neurol.=20 Neurosurg. Psychiatry 69: 292-301 [Full text] = =20
May, J., Chan, C. H., King, A., Williams, L., French, G. L. = (2000).=20 Time-kill studies of tea tree oils on clinical isolates. J = Antimicrob=20 Chemother 45: 639-643 [Abs= tract]=20 [Full=20 text] =20
Michiels, B., Avonts, D., van Royen, P., Denekens, J. (2000). GPs = can=20 improve their hand washing habits. BMJ 320: 869-869 [Full = text]=20 =20
Cookson, B. (2000). Infection and antimicrobial prescribing = control in the=20 new millennium: nightmare or nirvana?. J. Clin. Pathol. 53: = 66-70=20 [Full=20 text] =20
Weeks, A., Sen, R., Keaney, M., Trail, A., Howard, C., Chadwick, = P.,=20 Kesavan, S, Welbourn, C R. B, Jones, S. M, Hateley, P. M, Jurnaa, P A, = MacDermott, R., Varghese, D, Patel, H, Katme, A M. (1999). Hand = washing.=20 BMJ 319: 518-518 [Full = text]=20

Rapid Responses:

Read all Rapid=20 Responses

Handwashing study in a teaching hospital=20: P Badrinath
bmj.com, 13 Mar 1999 [Full = text]=20
Hand Wash- When is it necessary=20: Rajesh Mistry
bmj.com, 15 Mar 1999 [Full = text]=20
Nursing Homes=20: Johan Bots
bmj.com, 14 Mar 1999 [Full = text]=20
Participatory tools for assessing hygiene = practices=20: Astier M Almedom
bmj.com, 15 Mar 1999 [Full = text]=20
Is alcoholic hand rub the solution?=20: M R Budhoo
bmj.com, 19 Mar 1999 [Full = text]=20
Small wonder that few wash their hands=20: Nicholas Mayne
bmj.com, 19 Mar 1999 [Full = text]=20
Methods to motivate handwashing in the NICU=20: Edwin Dias
bmj.com, 20 Mar 1999 [Full = text]=20
Why I don't handwash between each patient = contact.=20: Andrew Weeks
bmj.com, 21 Mar 1999 [Full = text]=20
Handwashing=20: Rachel Sen
bmj.com, 23 Mar 1999 [Full = text]=20
Handwashing in postgraduate medical examinations=20: Richard P Hobson
bmj.com, 23 Mar 1999 [Full = text]=20
Now wash your hands....=20: Norman Macdonald
bmj.com, 23 Mar 1999 [Full = text]=20
Environmental contamination of school washrooms in the = United=20 Kingdom.=20: Ronald A Dixon
bmj.com, 23 Mar 1999 [Full = text]=20
Hand washing=20: Paul Bradley
bmj.com, 24 Mar 1999 [Full = text]=20
Alcohol hand rubs are better than soap and water=20: C Richard, et al.
bmj.com, 6 Apr 1999 [Full = text]=20
Can doctors fomites transmit infection too?=20: Allistair Stark
bmj.com, 22 Apr 1999 [Full = text]=20
In many hospitals' toilets soap and paper towels are not=20 provided=20: A Agrawal
bmj.com, 22 Apr 1999 [Full = text]=20
We should all wash our hands=20: C Ang, et al.
bmj.com, 19 May 1999 [Full = text]=20
S-CleanWipe=20: Eugene Sherry
bmj.com, 18 Jun 1999 [Full = text]=20
Improving handwashing facilities can contribute towards = good hand=20 hygiene=20: Y Drabu, et al.
bmj.com, 18 Jun 1999 [Full = text]=20
Exams should require hand washing=20: Elizabeth S R Darley
bmj.com, 17 Jul 1999 [Full = text]=20
Also general practitioners can improve their hand washing=20 habits.=20: Michiels Barbara
bmj.com, 25 Oct 1999 [Full = text]=20
Response=20: Kenneth Seaton
bmj.com, 2 Nov 1999 [Full = text]=20
Can British medical students pass their final examinations = without=20 washing their hands?=20: M Thorpe, et al.
bmj.com, 23 Dec 1999 [Full = text]=20
Danger of alcohol gel in the eyes=20: Paul Miller
bmj.com, 22 Mar 2007 [Full = text]=20
Re: Danger of alcohol gel in the eyes=20: Phillip J. Colquitt
bmj.com, 23 Mar 2007 [Full = text]=20
Danger of alcohol gel in the stomach=20: Emma Stapleton
bmj.com, 23 Mar 2007 [Full = text]=20

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