t
INFECTION PREVENTION AND CONTROL
Of course, the risk skyrockets when staff change wound dressings, handle a ventilator, or otherwise come in contact with blood, body fluids, or mucous membranes. In a French study, 24% of healthcare workers’ hands were contaminated with Clostridium difficile spores after routine care of patients infected with the bacteria.17 Infection control experts agree hand hygiene is the single most effective way of reducing healthcare associated infections. “During the past 20 years, we have predominantly concentrated on improving compliance,” said Prof Assadian. Building on WHO’s “Clean care is safer care” and “My five moments for hand hygiene” initiatives, countries and regions have launched their own campaigns, such as: “Germs. Wash your hands of them” in Scotland; “Stop! Clean your hands” in Canada; and “Clean hands save lives” in New South Wales, Australia. At every turn, healthcare workers are reminded to squirt enough alcohol-based hand rub, to use paper towels when turning off the faucet, to remove gloves properly, to perform antisepsis between patients and procedures. Training classes, videos, posters, stickers, slogans, voice prompts – hospitals employ all manner of tactics to boost compliance. A Brazilian hospital even aired catchy musical parodies over the in-house radio.18 Scotland’s National Health Service included reminders in staff pay slips, promoting Scotland’s “requirement of a zero tolerance approach to non-compliance with hand hygiene.”19
There’s just one problem with the motivational approach: “Realistically,” said Prof Assadian, “it is not sustainable.” Even when hand rub is readily available, when dispensers and sinks are in working order, when policies and procedures are visible, when healthcare workers are reprimanded with “tickets” or enticed with ski passes, compliance remains – to use WHO’s term – “abysmally low.”20
“Even in resource-rich settings,” WHO
reported, “compliance can be as low as zero percent, with compliance levels most frequently well below 40%.”21 Study after study finds critical hand- hygiene lapses. Healthcare workers do not rub adequately, use enough hand rub, or clean the back of their hands. They leave their wrists exposed, touch dispensers with their fingers, attempt to disinfect wet hands, or forget to remove wedding rings. They perform clinical work with seriously damaged
WHO, five moments for hand hygiene
We are trying to solve problems of today with instruments of the past. It is time to rethink our approach and combine existing
strategies with new technology. Ojan Assadian, MD, Infectious disease consultant and president of the Austrian Society for Infection Control
hand skin and mistake “washing” for “disinfection.”22
As researchers concluded,
“Even those workers who fully realise the importance of hand disinfection often do not know in what cases hand disinfection should be carried out unconditionally.”23 Based on observations and
questionnaires, a Ukrainian/German team concluded that 76% of healthcare workers miss at least one key moment, among WHO’s “Five Moments,” for hand disinfection. Much of the documented noncompliance pertains to gloves – for example, healthcare workers will put on wet gloves, remove gloves using an improper technique, or neglect to change gloves when indicated.24 In a study of six wards at a London hospital, gloves were used inappropriately in 42% of observed episodes, including 92% of low-risk procedures; healthcare workers often failed to remove gloves or to perform hand hygiene after wearing gloves.25
Other
researchers reported similar results: More than 60% of participants did not disinfect their hands before putting on gloves, and 80% disregarded hand disinfection upon taking gloves off.24 Proper glove removal is critical, as research demonstrates how easy it is to contaminate skin or clothing upon removing protective gear. In an American study, doctors, nurses, and phlebotomists at four hospitals put on their gloves and gowns in their usual manner, rubbed fluorescent lotion between their hands to simulate dirtied gloves, and then smeared the gloves over their chest and abdomen. After glove removal, black light showed a “contamination” rate of 52.9%.26 Hand-hygiene compliance tends to be worse when gloves are worn than when they aren’t. A study titled “The dirty hand in the latex glove,” conducted at 15 English and Welsh hospitals, found hand hygiene compliance among doctors was 41% when they wore gloves - and 50% when they didn’t.27
Common problems with outsourced cleaners SEPTEMBER 2018
Often it is forgotten that gloves will not protect patients but, at best, their wearer. Even then, gloves do not provide complete protection, as pathogens can penetrate small defects in the gloves and can be transferred to hands during glove removal. Testing shows a small percentage of brand-new sterile gloves may harbor defects, and 4% of gloves may become perforated even when healthcare workers wear two
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