- Mayo Clin Proc. 2004 Jan;79(1):109-16.
Hand hygiene: a frequently missed lifesaving opportunity during patient care. Trampuz A, Widmer AF.
Division of Infectious Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA.
This 8-page paper from the Proceedings of the Mayo Clinic provides a coherent summary of the background and references supporting the contention that improving hand hygiene practices improves patient outcomes by reducing hospital-acquired infections. The paper also provides a good summary of the CDC Guidelines for those who care for patients. This document might be a good resource for those who do not want to read the full-length CDC Guidelines.
Full text available at: http://www.mayo.edu/proceedings/2004/jan/7901crc.pdf
Mayo Clin Proc. 2004 Jan;79(1):109-16.
Hand hygiene: a frequently missed lifesaving opportunity during patient care.
Trampuz A, Widmer AF.
Health care-associated infections constitute one of the greatest challenges of modern medicine. Despite compelling evidence that proper hand washing can reduce the transmission of pathogens to patients and the spread of antimicrobial resistance, the adherence of health care workers to recommended hand-hygiene practices has remained unacceptably low. One of the key elements in improving hand-hygiene practice is the use of an alcohol-based hand rub instead of washing with soap and water. An alcohol-based hand rub requires less time, is microbiologically more effective, and is less irritating to skin than traditional hand washing with soap and water. Therefore, alcohol-based hand rubs should replace hand washing as the standard for hand hygiene in health care settings in all situations in which the hands are not visibly soiled. It is also important to change gloves between each patient contact and to use hand-hygiene procedures after glove removal. Reducing health care-associated infections requires that health care workers take responsibility for ensuring that hand hygiene becomes an everyday part of patient care.
Abstract available at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14708954&dopt=Abstract
- J Hosp Infect. 2001 Aug;48 Suppl A:S40-6.
Compliance with hand disinfection and its impact on hospital-acquired infections. Pittet D.
Infection Control Programme, University of Geneva Hospitals, Switzerland.
This paper probably provides the best real-world evidence base for reducing hospital-acquired infections by improving hand hygiene. In summary, overall hand hygiene practices were increased from 48% to 66% compliance and hospital-acquired infections went from 16.9% to 9.9%. The picture it paints isn’t entirely rosy because physicians were not seen to improve their hand hygiene practices, and to achieve their overall gains, the hospital maintained a constant and ongoing program to reaffirm and constantly reinforce the importance of hand hygiene practices.
J Hosp Infect. 2001 Aug;48 Suppl A:S40-6.
Compliance with hand disinfection and its impact on hospital-acquired infections.
Pittet D.
Infection Control Programme, University of Geneva Hospitals, Switzerland. didier.pittet@hcuge.ch
Hand hygiene prevents cross-infection in hospitals, but adherence to guidelines is poor among healthcare workers. Although some interventions to improve compliance have been successful, none had achieved lasting improvement until very recently. Reasons for non-compliance with recommendations occur at individual, group and institutional levels. The complexity of the process of behavioural change would suggest that the application of multimodal, multidisciplinary strategies are necessary. Both easy access to hand hygiene in a timely fashion and skin protection appear necessary prerequisites for satisfactory hand hygiene behaviour. Alcohol-based hand-rub may be superior to traditional handwashing as it requires less time, acts faster, irritates hands less often, and recently proved significantly to contribute to sustained improvement in compliance associated with decreased infection rates. This paper reviews barriers to appropriate hand hygiene and describes the results of the first successful experience of sustained hand hygiene promotion and its effectiveness on hospital-acquired infection.
Abstract available at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11759025&dopt=Abstract
- Am J Infect Control. 2003 Apr;31(2):109-16.
Use of alcohol hand sanitizer as an infection control strategy in an acute care facility. Hilburn J, Hammond BS, Fendler EJ, Groziak PA.
Texas Society of Infection Control Practitioners, Houston, USA.
This paper describes a program to the introduce an alcohol handrub and to recommend its use to health care workers and patients in an orthopedic surgery unit in a large Texas hospital. The mean monthly infection rate for the unit before the introduction of alcohol handrub was 8.2%; afterwards it was 5.3%, a 36% reduction. The paper also does a financial analysis that shows a mean cost per infection of over $4800, with a standard deviation slightly larger than the mean. The primary infections in this setting were urinary tract and surgical site infections.
Am J Infect Control. 2003 Apr;31(2):109-16.
Use of alcohol hand sanitizer as an infection control strategy in an acute care facility.
Hilburn J, Hammond BS, Fendler EJ, Groziak PA.
Texas Society of Infection Control Practitioners, Houston, USA.
BACKGROUND: Nosocomial infections are a major problem in health care facilities, resulting in extended durations of care, substantial morbidity and mortality, and excess costs. Since alcohol gel hand sanitizers combine high immediate antimicrobial efficacy with ease of use, this study was carried out to determine the effect of the use of an alcohol gel hand sanitizer by caregivers on infection types and rates in an acute care facility. Patients were educated about the study through a poster on the unit, and teachable patients were given portable bottles of the alcohol hand gel for bedside use, along with an educational brochure explaining how and why to practice good hand hygiene. METHODS: Infection rate and type data were collected in 1 unit of a 498-bed acute care facility for 16 months (February 2000 to May 2001). An alcohol gel hand sanitizer was provided and used by caregivers in the orthopedic surgical unit of the facility during this period. RESULTS: The primary infection types (more than 80%) found were urinary tract (UTI) and surgical site (SSI) infections. Infection types and rates for the unit during the period the alcohol hand sanitizer (intervention) was used were compared with the infection types and rates for the same unit when the alcohol hand sanitizer was not used (baseline); the results demonstrated a 36.1% decrease in infection rates for the 10-month period that the hand sanitizer was used. CONCLUSION: This study indicates that use of an alcohol gel hand sanitizer can decrease infection rates and provide an additional tool for an effective infection control program in acute care facilities.
Abstract available at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12665745
- Emerg Infect Dis. 2001 Mar-Apr;7(2):174-7.
The impact of hospital-acquired bloodstream infections. Wenzel RP, Edmond MB.
Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia, USA.
This paper is the primary source for many of the projections quoted in other papers as to the number of patients that die due to hospital-acquired infections. The number of deaths projected are for bloodstream infections only, are based on 35 million inpatient admissions annually, and range from 8,750 to 105,500 based on assumptions regarding attributable mortality and the overall nosocomial infection rate. (If the VA’s admissions for FY 2003, 567,300 is substituted for 35 million, the corresponding extrapolated overall deaths in VA due to bloodstream infections range from 142 to 1,702.) In addition to providing projections as to the harm caused by typical nosocomial infections, the author sites references to studies that indicate that improved hand hygiene can reduce the incidence of bloodstream infections. A point to remember is that the numbers projected in this study include bloodstream infections only and do not include infections such as upper respiratory infections and those transferred by the fecal-oral route, both of which are known to be spread predominantly by hand to hand contact.
Full text at: http://www.cdc.gov/ncidod/eid/vol7no2/wenzel.htm
Emerg Infect Dis. 2001 Mar-Apr;7(2):174-7.
The impact of hospital-acquired bloodstream infections.
Wenzel RP, Edmond MB.
Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia, USA. rwenzel@hsc.vcu.edu
Nosocomial bloodstream infections are a leading cause of death in the United States. If we assume a nosocomial infection rate of 5%, of which 10% are bloodstream infections, and an attributable mortality rate of 15%, bloodstream infections would represent the eighth leading cause of death in the United States. Because most risk factors for dying after bacteremia or fungemia may not be changeable, prevention efforts must focus on new infection-control technology and techniques.
- Emerg Infect Dis. 2001 Mar-Apr;7(2):234-40.
Improving adherence to hand hygiene practice: a multidisciplinary approach. Pittet D.
University of Geneva Hospitals, Geneva, Switzerland.
This paper contains wide-ranging data, information, and references to the relationship between hand hygiene practices and hospital acquired infections, as well as to the kinds of efforts that have been taken to improve hand hygiene. The paper begins with the statement that “Hand hygiene is the simplest, most effective measure for preventing nosocomial infections,” and ends with “The challenge of hand hygiene promotion could be summarized in one question: How can health-care workers' behavior be changed? Tools for change are known; some have been tested, and others need to be tested. Some may prove irrelevant in the future; others have worked in some institutions and need to be tested in others. Infection control professionals should promote and conduct outstanding research and provide solutions to improve health-care worker adherence with hand hygiene and enhance patient safety.”
Full text at: http://www.cdc.gov/ncidod/eid/vol7no2/pittet.htm
Emerg Infect Dis. 2001 Mar-Apr;7(2):234-40.
Improving adherence to hand hygiene practice: a multidisciplinary approach.M
Pittet D.
University of Geneva Hospitals, Geneva, Switzerland. didier.pittet@hcuge.ch
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.
- Clin Infect Dis. 1999 Nov;29(5):1287-94. 7.
Skin hygiene and infection prevention: more of the same or different approaches? Larson E.
Columbia University School of Nursing, 630 West 168th Street, New York, New York 10032, USA.
This article can be seen as a precursor to the CDC Hand Hygiene Guidelines issued in 2002. The following subtopics are identified and addressed in the article: Does Skin Cleansing Reduce the Risk of Infection? Effects of Hygienic Practices on the Skin; and Skin Care Practices for the Health Professional. Over 100 references are provided for the information presented.
Full text available at: http://www.journals.uchicago.edu/CID/journal/issues/v29n5/990351/990351.html
Clin Infect Dis. 1999 Nov;29(5):1287-94.
Skin hygiene and infection prevention: more of the same or different approaches?
Larson E.
Columbia University School of Nursing, 630 West 168th Street, New York, New York 10032, USA.
ell23@columbia.edu
The purpose of this article is to review research indicating a link between hand hygiene and nosocomial infections and the effects of hand care practices on skin integrity and to make recommendations for potential changes in clinical practice and for further research regarding hand hygiene practices. Despite some methodological flaws and data gaps, evidence for a causal relationship between hand hygiene and reduced transmission of infections is convincing, but frequent handwashing causes skin damage, with resultant changes in microbial flora, increased skin shedding, and risk of transmission of microorganisms, suggesting that some traditional hand hygiene practices warrant reexamination. Some recommended changes in practice include use of waterless alcohol-based products rather than detergent-based antiseptics, modifications in lengthy surgical scrub protocols, and incorporation of moisturizers into skin care regimens of health care professionals.
An excellent letter following up on the paper above was published several months later. The point that this author makes is that Semmelweis did not advocate hand washing with soap and water, but advocated hand decontamination with a disinfectant rinse (even though he didn’t understand the basic nature of microorganisms that cause infection).
Clin Infect Dis. 2000 Jun;30(6):990-1.
Handwashing-the Semmelweis lesson misunderstood?
Full text available at: http://www.journals.uchicago.edu/CID/journal/issues/v30n6/000047/000047.html
- Emerg Infect Dis. 2001 Mar-Apr;7(2):225-30.
Hygiene of the skin: when is clean too clean? Larson E.
Columbia University School of Nursing, New York, New York, USA.
This paper begins: “For over a century, skin hygiene, particularly of the hands, has been accepted as a primary mechanism to control the spread of infectious agents. Although the causal link between contaminated hands and infectious disease transmission is one of the best-documented phenomena in clinical science, several factors have recently prompted a reassessment of skin hygiene and its effective practice.” The author, who is one of the most widely published in this field, addresses a wide variety of questions and contrasts the needs in healthcare settings with those of other setting such as the home.
Emerg Infect Dis. 2001 Mar-Apr;7(2):225-30.
Hygiene of the skin: when is clean too clean?
Larson E.
Columbia University School of Nursing, New York, New York, USA. ell23@columbia.edu
Skin hygiene, particularly of the hands, is a primary mechanism for reducing contact and fecal-oral transmission of infectious agents. Widespread use of antimicrobial products has prompted concern about emergence of resistance to antiseptics and damage to the skin barrier associated with frequent washing. This article reviews evidence for the relationship between skin hygiene and infection, the effects of washing on skin integrity, and recommendations for skin care practices.
Full text available at: http://www.cdc.gov/ncidod/eid/vol7no2/larson.htm
- N Engl J Med. 2004 Mar 25;350(13):1283-6.
On washing hands. Gawande A.
Department of Surgery, Brigham and Women's Hospital, Boston, USA.
This is a first-person rumination by Dr. Atul Gawande on the history and the importance of the topic of hand hygiene, and the problems associated with getting physicians (including himself) to comply with agreed-upon good practices in this area. Dr. Gwande has been widely published on medical topics in both professional journals and highly regarded lay publications such as the New Yorker. Dr. Gawande is also surgeon and the author of the book “Complications.”
Full text (free to VA employees) available at: http://content.nejm.org/cgi/content/full/350/13/1283
N Engl J Med. 2004 Mar 25;350(13):1283-6.
On washing hands.
Gawande A.
Department of Surgery, Brigham and Women's Hospital, Boston, USA.
No Medline summary available. An excerpt from the article follows:
“Anything short of a Semmelweis-like obsession with hand washing has begun to seem inadequate. Yokoe, Marino, and their team have now resorted to doing random spot checks on the floors. On a surgical ICU, they showed me what they do. They go directly into patients' rooms. They check for unattended spills, toilets that have not been cleaned, faucets that drip, empty gel dispensers, overflowing needle boxes, inadequate supplies of gloves and gowns. They check whether the nurses are wearing gloves when they handle patients' dressings and catheters. And, of course, they watch to see whether everyone is washing up. Neither hesitates to confront people, though they try to be gentle about it. ("Did you forget to gel your hands?" is a favored line.) Staff members have come to recognize them. I watched a gloved and gowned nurse come out of a patient's room, pick up the patient's chart, see Marino, and immediately stop short. "I didn't touch anything in the room! I'm clean!" she blurted out. “
“They hate this aspect of the job. They don't want to be infection cops. It's no fun, and it's not necessarily effective, either. With 12 patient floors and four different patient pods per floor, they can't stand watch the way Semmelweis did, leering over the lone sink on his unit. And they risk having the staff revolt as Semmelweis's staff did. But what other options remain?”
