The Work Health and Safety Act 2011 is about ‘protecting workers and other persons against harm to their health, safety and welfare’. For nurses and other health professionals, this includes infection control measures and means that effective hand washing is an essential and legally required task in the workplace.
Between 1977 and 2011, there have been more than 20 hospital based studies of the impact of hand washing on healthcare associated infections (HAIs). Almost every study reported a correlation between improved hand washing, and reduced infection and cross-transmission.
It should be noted that although alcohol based hand rub has been shown to have an impact on reduced infection rates – the ultimate success is down to increased hand washing compliance.
Around 1 in 10 people admitted to a hospital will develop a hospital acquired infection which can drastically change their mortality and morbidity odds, and increasing hospital costs. As antibiotic resistance grows, the incidences of HAIs will also rise – so it’s essential that we’re doing everything we can to reduce the risk of infection transmission.
There is mounting evidence that improved hand hygiene can reduce infection rates.
So, what causes a hospital acquired infection?
Bacteria alone causes around 90%, with the remaining 10% through fungus and viruses. Some of the commonly responsible bacteria include:
- Staphylococcus aureus
- Escherichia coli
- Pseudomonas aeruginosa
Bacteria, fungi and viruses are spread predominantly through person-to-person contact which can include unclean hands, in addition to handling contaminated medical instruments, and other hospital equipment.
You don’t have to directly touch a patient for infection to spread – simply touching an infected door handle could allow some bacteria to spread through a hospital and be picked up by another patient.
Cross contamination occurs through a multi-step process.
- Organisms are present – either on skin, or inanimate objects
- Organisms are then transferred to the hands of the healthcare worker
- The organisms survive on their skin for several minutes
- Inadequate or absent hand hygiene causing the organism to remain
- Direct contact with a patient enabling transmission
As you can see, simply washing the hands or using an alcohol rub immediately after picking up the organisms would prevent their ability to survive on the skin and be passed on to someone, or something else.
But it’s not just hospitals where infection can spread, and good hand hygiene is important. Aged care facilities and community practice have just as many risks to the health worker and the patient. Although bacteria are often found on the hands of medical professionals following patient care activities such as wound care, handling patient secretions, etc. – bacteria have also been found after ‘clean contact’ such as taking a patient’s blood pressure, or pulse.
What is the correct hand washing technique for good hand hygiene?
It’s important that we know when to wash our hands before we consider the best technique for doing so. Hand Hygiene Australia have identified ‘5 moments for hand hygiene’ which include:
- before touching a patient
- before a procedure
- after a procedure or body fluid exposure
- after touching a patient
- after touching a patient’s surroundings.
(Hand Hygiene Australia 2017)
The commonly held thought is that it’s only before or after direct patient contact that it becomes necessary to wash our hands but clearly there are so many more instances where we can pick up infection carrying organisms.
One of the key risks is that the organisms are invisible and we cannot know they are there, it’s crucial that good hand hygiene becomes more than a habit but second nature.
The WHO guidelines for hand washing recommend singing ‘Happy Birthday’ twice whilst going through the following steps (follow the link for images):
- Wet hands with water and apply enough soap to cover all hand surfaces
- Rub hands palm to palm, then right palm over left dorsum with fingers interlaced
- Palm to palm with fingers interlaced followed by backs of fingers to opposing palms with fingers interlocked
- Rotational rubbing of left thumb clasped in right palm, and vice versa
- Rotational rubbing back and forth with clasped fingers of right hand in left palm, and vice versa
- Rinse hands with water with palms facing down
- Dry thoroughly with a single use towel
- Turn the tap off with the towel
Despite the clear need for good hand hygiene, there are many obstacles that appear to be preventing it becoming routine amongst healthcare professionals. Some of these are down to poor perception – such as patient need taking priority over hand washing, that gloves are an effective barrier or a lack of understanding of cross contamination. Whereas institutional problems can also be a barrier, such as not enough hand washing stations, staff shortages, lack of policy, or simple forgetfulness.
Frequent hand washing audits can be a great way of improving compliance.
Direct observation from a colleague or manager is one of the best ways of ensuring that good hand hygiene is being carried out throughout a department, practice, or aged care facility. It’s all down to the Hawthorne effect – when people know they are being watched they’ll change their behaviour accordingly. By having a work colleague be the observer, the risk of being caught out is too great – so the behaviour continues.
Greater awareness amongst patients and family can also be of benefit. Not only is it crucial for everyone in a hospital or care facility to wash their hands effectively and prevent cross contamination, but they can hold medical professionals to account with a simple reminder ‘have you just washed your hands?’.
There is, of course, a place for alcohol-based hand rub to be used in healthcare settings.
It’s quicker to use, is less irritating than soap and water, and dries naturally. However, alcohol rub should never be used as a sole substitute for hand washing. Though great for keeping on top of infectious organisms, hand washing is still more effective at dealing with bacteria under the fingernails.
The battle against hospital acquired infection continues, and with antibiotic resistance ever increasing, there shows little sign of it stopping soon. Effective hand hygiene is one of the simple steps every nurse, midwife and medical professional can take to help combat infection and protect their patients from harm.
- ACT Parliamentary Council 2016, Work Healthy and Safety Act 2011, Canberra, ACT, viewed 18 August 2017, http://www.legislation.act.gov.au/a/2011-35/current/pdf/2011-35.pdf
- Centre for Healthcare Related Infection Surveillance and Prevention & Tuberculosis Control 2013, Guideline – Hand Hygiene, Version 2, Queensland Government, QLD, viewed 18 August 2017, https://www.health.qld.gov.au/__data/assets/pdf_file/0018/151146/qh-gel-321-1-1.pdf
- Edmond, M, Landon, E, Larson, E & Price, C 2014, ‘Infection prevention in hospitals: The importance of hand hygiene’, Infectious Disease News, Healio, viewed 18 August 2017, https://www.healio.com/infectious-disease/nosocomial-infections/news/print/infectious-disease-news/%7Bdd1e115b-8a00-4889-9e85-8566391f2541%7D/infection-prevention-in-hospitals-the-importance-of-hand-hygiene
- Hand Hygiene Australia 2017, 5 Moments For Hand Hygiene, HHA, Australian Commission on Safety and Quality in Health Care, viewed 18 August 2017, http://www.hha.org.au/UserFiles/file/Manual/HHA_Manual_June_2017.pdf
- Stubblefield, H 2016, ‘What Are Nosocomial Infections?’, Healthline, 24 October, viewed 18 August 2017, http://www.healthline.com/health/hospital-acquired-nosocomial-infections#takeaway9
- World Health Organisation 2017, Clean Care is Safer Care: Clean hands protect against infection, WHO, viewed 18 August 2017, http://www.who.int/gpsc/clean_hands_protection/en/