“Hand hygiene” — it’s a fancy way of saying “clean your hands when you should.” Sound like a nagging comment from mom? It’s actually the most effective thing a health care worker can do to reduce the spread of infectious disease, especially for those in the hospital. But unfortunately, health care workers may not be doing everything they should to lower that risk.
According to the Centers for Disease Control and Prevention (CDC), about 1 in 25 patients gets a health care-associated infection during their hospital care, adding up to about 722,000 infections a year. Of these, 75,000 patients die of their infections.
One way that health care workers are putting patients at risk? Not performing proper hand hygiene, including washing their hands (either with hand sanitizer or soap and water, depending on the scenario) before and after certain tasks, and performing those tasks in an order that most reduces the risk. For example, many workers move from care tasks that are considered “dirty” to care tasks considered “clean,” which increases the risk of infection — like touching a patient’s body fluids and then touching that same patient’s intact skin, without cleansing their hands in between (um… gross). Per an observational study in which researchers assessed 18 intensive care unit (ICU) centers across the United States for a total of 3,246 hours, ICU health care workers moved from dirtier to cleaner tasks in two-thirds of instances.
And while many health care workers use gloves, the research from the observational study — which was presented at the recent European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) in Amsterdam — showed that people were less apt to wash their hands when they’d been wearing gloves, even though it’s wise to do so anyway. Researchers also found that gloved health care workers were more likely to move from dirtier to cleaner tasks without changing those gloves (which means what you think it means: Germs on gloves just get moved from place to place).
Additionally, physicians were 50% more likely to move from dirtier to cleaner tasks than nurses, and health care workers like radiology techs and respiratory therapists were more than twice as likely to move from dirty to clean tasks as well — which could be especially concerning in cases when respiratory germs are being transferred around a hospital.
Most startling of all? (As if you’re not startled already!) The researchers observed that health care workers only used proper hand hygiene in half the instances when moving from dirtier to cleaner tasks, and in around 43% of the opposite cleaner-to-dirtier instances.
"Our findings indicate that health care workers may inadvertently increase patients' risks for health care-associated infection by the direction in which they do tasks," says researcher Loreen Herwaldt, M.D., a professor of internal medicine and infectious diseases at the Lucille A. Carver College of Medicine in Iowa City, Iowa, in a press release. "We need to identify interventions that will help health care workers organize their work in a way that decreases this risk and also reduces their workloads." And they just need to wash their hands and change their gloves when they’re supposed to — period.
Hand hygiene really works
To cut the risk of health care-associated infections, the World Health Organization’s (WHO) “5 Moments for Hand Hygiene” lay it out clearly:
- Before touching a patient
- Before a clean procedure
- After exposure to body fluids or wounds
- After touching a patient
- After touching a patient’s surroundings
In Australia, the National Australian Hand Hygiene Initiative (NHHI) aimed to emphasize these WHO tips to see whether they could reduce the nationwide risk of Staphylococcus aureus, a potentially fatal health care-associated infection.
"Hospital-acquired infections are a major concern for hospitals around the world, and S. aureus is among the most dangerous," said infectious disease specialist Lindsay Grayson, M.D., director of Hand Hygiene Australia, who led the research, in a press release. "The risks to patients are enormous, as are the associated hospital costs. Despite robust evidence supporting improved practices for hand hygiene, securing compliance is notoriously difficult, and few national programs have been sustained in the long-term."
Their analysis found hand hygiene compliance in Australian hospitals improved throughout the eight-year NHHI campaign, with people performing hand hygiene during 84% of available hand hygiene “moments” in 2017, up from 64% in 2009.
So what’s the right way to wash your hands?
It’s not like doctors haven’t heard this before — there are basic rules in place for health care workers to ensure proper hand hygiene, and hand-cleansing instructions and reminders are often posted throughout hospitals and doctor’s offices.
According to the WHO’s research-based guidelines, the preferred way for health care professionals to clean their hands is with an alcohol-based hand rub (AKA hand sanitizer) — it’s faster, more effective, and not as hard on the hands as traditional soap-and-water washing. However, there’s a major caveat: If a health care worker’s hands are visibly dirty or they’ve just used the toilet, washing the hands with soap and water is preferred. WHO has a handy poster that shows how to use both methods.
The Centers for Disease Control and Prevention (CDC) take the washing-versus-sanitizer debate even further: In addition to the two exceptions WHO cites, the CDC recommends health care workers use soap and water to wash in the following scenarios:
- After known or suspected exposure to the bacteria Clostridium difficile if their facility is experiencing an outbreak or higher endemic rates
- After known or suspected exposure to patients with infectious diarrhea during norovirus outbreaks
- If exposure to Bacillus anthracis is suspected or proven
- Before eating
Alcohol-based hand sanitizer is OK for any scenario not included in the above list, the CDC says.
And yet: Even that isn’t as simple as it would seem. For hand rubbing with sanitizer, WHO recommends health care workers follow a six-step, 30-second technique for the most effective results — here’s a video that shows how it’s done (yeah, it’s kind of an intense process). According to previous research, most health care workers don’t follow these steps correctly.
Luckily, new research, also presented at the ECCMID, finds that a simplified version that shortens the technique by half is equally effective at killing bacteria — and could boost compliance.
In the new study, University Hospital Basel, Switzerland researchers had 20 healthy volunteers use each of these four different hand hygiene techniques to see how they each lowered bacterial counts:
- The six-step hand hygiene technique for 30 seconds
- The six-step hand hygiene technique for 15 seconds
- The three-step hand hygiene technique for 30 seconds
- The three-step hand hygiene technique for 15 seconds
Three steps and 15 seconds, it turned out, was just as effective at killing bacteria as the 30-second, six-step rub recommended by WHO.
"The time pressure and heavy workload experienced by health care workers reduces compliance with hand hygiene standards. Our findings suggest that shortening hand rubbing time and simplifying the technique for use of hand rub could be a safe alternative that is easier to fit into their busy routine, could enhance the overall quality of hand hygiene performance, and have a positive effect on adherence", said study author Sarah Tschudin-Sutter, M.D., in a press release. "Further studies are needed to validate the performance of the shorter application time in everyday clinical practice."
What if I’m not a health care worker?
For the rest of us, the hand hygiene guidelines are a little easier to remember.
According to the CDC, you should wash your hands in the following scenarios:
- Before, during, and after making food
- Before eating food
- Before and after caring for a sick person
- Before and after treating a cut or wound
- After using the restroom
- After changing diapers or cleaning up a child who has used the toilet
- After blowing your nose, coughing, or sneezing
- After touching an animal, animal feed, or animal waste
- After touching pet food or pet treats
- After touching garbage
The best method? Soap and water takes the win in most situations, but it’s OK to use hand sanitizer if it contains at least 60% alcohol, the CDC says. And when you’re washing your hands, just remember five simple steps: wet, lather, scrub (for 20 seconds!), rinse, and dry.