Is There Any Conclusive Evidence that Hand Washing Reduces or Cuts Down Cross Infection - Essay Example

Is there any conclusive evidence that hand washing reduces or cut down cross infection? Contents , page Introduction, page 2 Thesis andrationale, page 4 . Literature review, page 4 Discussion, page 13 Future Practice , page 15 Conclusion, page 18 Appendix 1 – Methodology , page 19 References , page 19 Abstract This essay is concerned with hand washing protocols and the way in which they affect cross infection levels in hospital situations. Consideration is given to the known close association between correct hand hygiene and lower levels of hospital cross infection levels. It points to the discrepancy that exists in many cases between knowledge and actual practice as demonstrated in various research projects. Several hospital based research projects on the subject are investigated and commented upon as are government campaigns and guidelines. There is discussion of how an assessment of the present situation can be made and then it goes on to describe changes needed in present practice, as well as how these might be carried out and assessed. Introduction As early as 1199 in his ‘Treatise on Hygiene’ Moses Maimonides taught that physicians should “never fail to wash their hands after touching a sick person.”1 In the late 17th and early 18th century in the Netherlands Anton van Leeuwenhoek was the very first person known to have seen bacteria using a microscope. 2 Later Frenchman Louis Pasteur, and Robert Koch in Germany in the 19th century, proved that many micro-organisms were the cause of infections and disease.3 Meanwhile Hungarian physician Ignaz Semelweis introduced a strict hand washing regime in his Austrian hospital. This practice was ridiculed by his peers, yet resulted in a huge cut in hospital mortality.4 Yet more than 150 years later there is still a problem, despite the discovery and development of many antiseptic and anti-bacterial products and drugs, especially from the mid 20th century onwards. Antibiotics were hailed as super drugs when they were developed in the mid-20th century, but however powerful they loose their effective power over time. From the later years of the 20th century on until the present time organisms such as MRSA (Meticillin-resistant Staphylococcus Aureus), as well as Enterococcus faecalis and Clostridium difficile, have been found to be the responsible agents in various cases of hospital acquired infections. This is despite the fact that the various health care bodies acknowledge the obvious importance of correct hand hygiene, but the problem persists and poor hand washing techniques or routines remain the commonest source of infection. Part of the problem may be that people, by the time they enter the health service as staff may believe they already know how to wash their hands correctly which can make them somewhat resistant or ‘switched off’. Infections acquired in hospital may especially damage patients as illness may have already caused them to have an immune system that is not working as efficiently as it might be. Also at particular risk are those who have or have had various pieces of equipment inserted, so providing pathways for infective organisms such as those with:- Surgical or other wounds Central venous catheters Urinary catheters Tracheostomies Peripheral intravenous cannula There is therefore an obvious need to reconsider and change current practice. Also, with regard to public-health, correct hand-washing patterns, as and when needed, are important because this helps to control the spread of infection and also reduces the need for medical intervention and the use of antibiotics. In 2007 the Scottish government considered the problem so large that it justified the launching of a national awareness campaign at a cost of £2.5 million pounds using the slogan . Germs - wash your hands of them.5 This campaign was in fact aimed at the whole Scottish nation, but this did include hospital staff at all levels. This was a huge investment, but the immense costs were not as high as those wasted on of hospital acquired infections, and these are of course are also associated with unnecessary disease and even deaths. The aim , as described by the then Scottish Minister of Health Andrew Kerr, aim was to bring about a change in both behaviour and and thereby reduce the number of incidences of easily avoidable sickness. Louise Teare gave her British Medical Journal article of March 1999 about hand hygiene describes it as ‘A modest measure with big effects.’6 She bases her statement on sound evidence as outlined below. Thesis and Rationale In recent years there has been an increase in cases of antibiotic resistant organisms causing severe difficulties and even fatalities in hospitals. There is evidence that this problem can to some extent be put at the door of health care staff who either fail to wash their hands or don’t do so adequately – either because of poor technique or because they don’t do it on every possible occasion for whatever reason. If carried out properly hand washing has been shown to produce a noticeable difference in the ability of pathogens to survive on the dermal surfaces of the hands. Literature Review The National Audit Office , February 2000 The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England7 The report gives up to date statistics with regard to hospital acquired infections. This occurs, the authors claim, to as many as 9% of hospital patients. It mentions the fact that all such infections are not preventable due to the particular susceptibility of certain patient groups such as the very young and others whose immune system is not fully functioning. They also state however 8that as high as 30% of hospital acquired infections are unnecessary, although much good practice was observed. Such positive practices need to be more widely known and then applied more widely. It was felt that there could often be more emphasis upon infection prevention and support for infection control workers. A patchy system of provision and practice was reported upon. It is pointed out how, from 1995 onwards, direct responsibility for effective prevention measures fall to chief executives, yet such persons are rarely actually involved. Despite it being generally known that hand washing can be regarded as one of the most effective of methods in the fight against cross infection in hospitals, it was found that 8% of National Health Service Trusts do not have an agreed hand washing policy in place. Also mentioned is the evidence that compliance levels with agreed protocols are lower than they might be. This is a long and well thought out document that includes a long list of recommendations.9 These include possible surveillance methods and other methods which it is suggested might serve to reduce infection rates. Delaney,L. and Gunderman,R, January 2008, Hand Hygiene, Radiology 246, 15-19, 10 The authors begin by quoting the United States Centers for Disease Control and Prevention (CDC) as having cited washing the hands as being as the one way to effectively prevent cross infection. Annual figures given are as high as 2 million nosocomial infections, and a shocking 90,000 fatalities across the United States. In the United Kingdom figures will be lower, but only because this is a relatively small country. Christine Case gives figures of 5% to 15% of inpatients acquiring infections during their hospital stay11. Some part of the problem they believe is due to simple misperception – people convince themsleves that they actually carry out hand washing more often than they actually do. And the discrepancy between belief and practice is huge. The example is given of surgeons12 in Melbourne, Australia.13 The doctors when surveyed stated that they washed their hands between a low of 50% and a high of 95% of appropriate opportunities. In fact they followed the agreed proceedures only 9% of the time. The authors cite various reasons why hand washing is not carried out correctly and then make a number of suggestions to help overcome these. If staff were made to realise such discrephancies an d links with infection levels it might help. McCormick R, Buchman T, Maki D., Double-blind, randomized trial of scheduled use of a novel barrier cream and an oil-containing lotion for protecting the hands of health care workers Using a double blind trial the researchers sought to measure the effects of using hand lotions in those health workers who had skin irritations. A gradual increase in hand washing frequency over a period of 4 weeks was noticed in such staff. The researchers concluded that the use of lotions containing oil or barrier creams as a regular thing on a could substantially protect the hands from chemical irritation and so promoted increased frequency of hand washing. This research is important in that it showed it was possible to change attitudes and practice in a positive way in a relatively short period by easily reproducible methods. Coward,J. et al, November 2009, Developing ward accreditation to improve infection control practice, Nursing Times.net14 Coward and his colleagues were concerned in this article with a ward accreditation audit scheme. This somewhat competative method was proved to directly relate to a drop in rates of hospital associated infections. Further it led to a standardisation in mehtods of infection control in the hospitals of Newcastle Upon Tyne The authors stress the importance of good leadership at all levels of health care. They explain that it is necessary to decide upon and then set out clear aims and ways of auditing results so that performance levels can be measured accurately. For this eduation and good communication were felt to be absolutely necessary in order to bring about any succesful change to be made in a health care situation. IGENE Voice Warning System 15 This was a review carried out by the National Health Service purchasing department into the effectiveness or otherwise of the IGENE voice warning system and was as objective as possible when considering the cost effectiveness of such a system. The technology was developed by Adroit Global Technologies and was meant to be used in areas where correct hand washing is considered essential. Any agreed message can be recorded for use. The authors state that in clinical settings the device was put in place against a background of staff education and knowledge on the subject of the effectiveness of hand washing as a disease preventative. The conclusion was that that there was not sufficient evidence to prove that the use of the device made any significant difference to frequency of hand washing among the staff concerned. Therefore, although it was agreed that hand washing was important, it was felt that this device did not make a sufficient contribution so as to improve practice. This report at least shows how the National Health Service is open to suggestions for innovative ways of dealing with a resistant problem. Jeanes, A., 2003, Improving hand hygiene compliance, Nursing Times.net 16 The author is particularly concerned with infection control in her work at Lewisham Hospital, London. She describes the efforts undertaken at that the hospital to improve hand hygiene among health care staff during a year long trial. She takes it as proved that good hand hygiene technique used at appropriate intervals ‘is acknowledged to be crucial in preventing the transmission of infections.’ citng Larson et al. 17. She then goes on to discuss how it came to be realised that new methods and products needed to be ‘sold ‘ to staff. Easy accessibility, the speed of anti-bacterial action and possible negative effects on the skin surfaces were felt to be important factors when trying to increase their levels of compliance. Marketing methods were used in order to convince staff of the acceptability and effectiveness of the newly introduced products. Various methods were used in an attempt to increase compliance levels. These included demonstrations which used glowing dye as well posters and lectures. All of these were found to have success only in the short-term. Upon consideration it was felt that a new approach was required. It was realised that weaknesses consisted in the main of a general lack of awareness of staff views by inhfection control staff. There was also a lack of backing from senior staff, and staff were not being kept informed about infection rates in their units. The author goes on to describe how , on a positive front, there were many standards, guidelines and relevent reports available on the subject of infection control. She lists papers issued by the Department of Health, the National Audit Office, and NHS Executive, all issued in 2000. Negatively it was felt to be difficult to introduce change and there would be some competition from other areas of priorty within the Trust. After describing various difficulties which were eventually overcome, such as the actual best places to place the products, the author was able to prove, in purely monetary terms, how positively effective the changes made were. This was calculated based upon the provable decrease in various infections sustained. Diarrhoea associated with Clostridium difficile-associated (CDAD) was found to be reduced by 17.4 per cent. Methicillin-resistant Staphylococcus aureus (HAMRSA) were reduced by a level of 11 per cent. This successful scheme could well be used as a positve apttern by other trusts. Doebbeling, B. et al, 1992, Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units,18 This study was carried out because, although it is known that effective hand-washing is known to prevent hospital borne infections, there have however been very few studies in a clinical situation of the efficacy or otherwise of particular hand-cleansing substances in preventing infection being passed by health care staff to the patients in their care. As far as purchasers are concerned the key factors are price, efficiency and possible side-effects. Staff directly involved may have other priorities such as smell or the fact that their skin becomes sticky or there is a stinging effect. The agents considered were chlorhexidine which is a broad-spectrum antimicrobial agent; 60 percent isopropyl alcohol and a non-medicated soap as another option. This was a large and long term study involving almost 2000 patients over a period of 8 months. Each product was tried for a period of four weeks and then changed over to the alternative agent. During the periods when chlorhexidine was used there were fewer infections than when alcohol were used in combination, the biggest changes being in the occurrence of gastrointestinal infections. It was also found that staff used rather more chlorhexidene than the alcohol based substance so presumably this was felt to be either more acceptable or more efficient but meant that in practice the use of chlorhexidine proved the more effective agent. This is something to be considered by infection control staff and those responsible for choosing products. Holyoake, D., September 2010, The Awkward Feeling campaign: confronting poor hand hygiene to improve handwashing, Nursing Times.19 This article describes how student nurses took place in a workshop which looked at the way in which they viewed hand washing. The aim was to focus on possible improvements in healthcare by re-thinking the motivating forces that are usually associated by health care staff with hand washing. The 22 third year students proved able to move themselves on from a position where they regarded hand washing as a simple, isolated hygiene task to seeing it rather as being a social act and part of a larger system of organisation. It was noted that the students challenged traditional messages promoting health issues which tended to focus upon ways in an individual could, by their actions, make a positive difference. The group discovered : There is a definate hierarchy of compliance offenders across all situations. Some health care staff will always claim, and perhaps believe, that they are keeping to the rules, even when it is obvious that they do not. This may be because hand washing is commonly thought of as voluntary, individual behaviour. If there was an emphasis upon the whole health community it was felt that effective hand washing practice would become the norm. The effectivenes of this workshop shows how staff at all levels can make a positive impact. Jeanes, A., October 2004, Handwashing: what is the best solution? Nursing Times20 The author points out how, as the true value of correct hand hygiene recieves wider publicity, various hand-hygiene substances have been developed. She goes on to describe how traditional handwashing regimes take considerable amounts time in a working day and can also have negative effects on health-care staff because they can produce dry, peeling skin or even cracks and produces contact dermatitis in some cases. She points out that products containing alcohol have proved to be both quick and easily accessible, but are not always acceptable or appropriate in all cases. Also pointed out is the way in which products and the facilities available vary from situation to situation – something that may to some extent be conditioned by cost factors. Also mentioned is the fact that the hands may be being washed for a number of reasons and this will affect the types of products required e.g. hands may be obviously contaminated with body fluids, a surgeon may be preparing for an operation or a nurse may simply be moving between patients. In the latter case simple alcohol rub may be all that is required whereas soap, being detergent-based and applied together with water, is more suitable for the removal of visible signs of soiling. Staff need to have a number of options available to them and should be encouraged to ask ‘Why am I washing my hands? and then make a suitable choice of method and cleansing agent. In some cases soap and water will be the obvious solution There are however several disadvantages to the use of soap products. Towels are required and even if disposables are used these need replacement and disposal. Unless liquid soap is used the soap itself can become contaminated as can taps etc. The whole process, although all staff may be familiar with it , takes noticably longer than using a rub. Discussion It can be conclusively proved that correct hand hygiene cuts down the number of skin borne pathogens and so reduces the possibility of cross infection in clinical situations. However different agents have differing qualities. Chlorhexidine, as Jeanes pointed out in 2004, 21has been proved to effective against gram positive bacteria , but is less active against fungi, some viruses and gram negative bacteria. It does however continue to work in the presence of organic substances such as blood and other body fluids.It does not work however in cases of tubercular bacilli according to Boyce and Pittet. 22 Nor can it be used in cases where there has been either eye or brain surgery as it can have a toxic effect upon the tissues involved. 23 However the product has been found to be both relatively effective and acceptability to users. Iodine based products ( idophour preperations) produce a wiser range of anti-bacterial activity. However they are quite quickly deactiviated by the presence of organic substances.24 According to Jeanes the National Health Purchasing and Supply Agency (NHS PASA) had by 2004 discovered that more than half of health care trusts in England had already introduced alcohol-based products at the point of care. This number was expected to increase in the near future. Such products are benificial when handwashing is not possible because of for instance time constraints. They:- Can be used when a greater degree of bacterial reduction is needed. They are also likely to cause less skin irritation than frequent hand washing. Such solutions can also be easily portable. There are however some disadvantages:- They are only suitable for use on hands which appear to be visibly clean to the naked eye. They act well against bacteria , but work less well when viruses are present. Repeated use over a short period of time can result in sticky hands. There is an obvious smell of alcohol. The products are flammable If there are minute cuts and scrathes the use of alcohol may cause pain. Jeanes also suggests other possible hand hygiene agents. 25These include include emollient soap substitute, antiseptic hand wipes, solutions based upon tea tree oil, and aqueous based solutions. Future Practice Although hand hygiene is an individual act, and to a great extent is seen as an individual responsibility, it is more likely that compliance levels will rise if it is also seen as being part of a whole and necessary system that needs to be in place for the better care of patients. This means that the various obstructions to high compliance levels must be overcome in a collective way by involving staff as much as possible in any decisions made about proceedures, positioning and the agents to be used. . Some health staff claim that over use of skin cleansers cause them to have irritiating rashes. The known effects on the skin of a particular product will have an affect, positive or negative on peoples desire to make use of it for the correct amount of possible opportunities. Agreed skin friendly cleaning agents should be easily available. In most cases this will mean using hand rubs which are alcohol based as compared with soaps, as these are generally better tolerated. Personal prefernces should be taken into account and , where suitable, different options made a vailalbe. Jeanes pointed out that while nurses continued to prefer hand washing, doctors generally tended to use hand gel. 26 As well as knowing that adequate hand washing contributes positively to patient well being and cuts cross infection levels, staff need to be aware of the value to skin integrity and that the regular use of hand lotions or creams can positively contribute to this. Knowledge that a particular cleansing agent has a degree of residual anti- bactericidal effect may well serve to encourage greater levels of compliance. Suitable materials need to be available at every hand washing station together with simple directions for their uses. These lotions and rubs should be contained in small, non-refillable units so that they don’t have the opportunity to themselves to become sources of resistant bacteria and consequent infection. Foot or elbow operated systems are most likely to result in lower levels of cross infection. Preliminary research into the present situation in a particular clinical situation is required. An audit of hand washing compliance should be made before such measures are undertaken. Targets should be set for increased levels of compliance. After their introduction, and the passing of an agreed period of time, another audit of hand washing compliance levels should be made. The results, when compared, should be made available to staff. This should identify new, higher, levels of compliance and so will show the level of success or failure of the changes made. It should serve to identify any areas where that agreed standards and weaker actions targeted while at the same time showing best practice.. The results of the changes made are thus both analyzed and affect future practice. After this second audit a number of questions are necessary. If targets considered to be appropriate were still not being met why was this? i.e. What went wrong? What is causing a block to positive progress? What could have been done to improve matters in order to overcome such obstacles to progress? Should the present agreed protocol be continued, or is there need for change –either minor or major? If of course targets are met then staff should be congratulated and urged to continue the good work. Further audits are needed at agreed intervals and if required there will be further changes in agreed procedures in order to maintain high levels of hand washing compliance. There can is be some resistance to frequent hand washing on the grounds that it is felt to be a waste of time better spent directly on patient care. Staff need to be aware that simple human action can prove to be a better preventative than drugs and will ultimately result in shorter and safer periods of hospitalisation for those in their care. In the cases where washing with soap and water is required non touch methods seem to be a way forward i.e. there are no taps or bars of soap and no towels, paper or otherwise, are used and so do not need disposal or replacement. The person merely places their hands under the tap and soap and water are released followed by air drying. Such systems are not suitable in every situation such as at the individual bed head. They would also prove to be expensive to install and maintain and this initial installation would cause at least some disruption as well as requiring some education on the part of staff. This cost and disruption must be balanced agains the greater cost of keeping patients in hospital for longer because they have developed antibacterial resistant infections. Also staff must be involved in decisions made. The approach used in Lewisham of marketing hand hygiene to staff produced a positive effect which was sustained. Such efforts do however require repeated audits of compliance levels and may need future revision according to changing situation such as the arrival of new staff or the development of pathogens that are resistant to the products in use. Someone must be responsible for compliance levels and such things as ensuring the supply and availability of needed products at the most suitable sites. . Conclusion The task of health care staff is to care and protect patients from harm while at the same seeking to restore them to health if this is possible. It can be proved that washing the hands cuts down enormously the number of harmful pathogens transmitted from one person to the next. It therefore follows that there must be a definate effort to both understand and to apply correct hand hygiene techniques and to encourage staff to follow such proceedures by making the corect materials and equipment available and also educating staff as to the most optimal techniques. This will then reduce the number and severity of hospital acquired infections. It must therefore be a priority to both come up with agreed and suitable proceedures and to promote them positively. Several hand hygiene products are readily available to health authorities within the United Kingdom.. These vary both as their suitability and efficacy in particular clinical situations. Staff should preferably in involved in any process of selection as this is likely to lead to greater levels of compliance and so lead to the best possible outcome for all concerned, primarily of course better patient care and reduced levels of cross infection. It must also be stressed that hand hygiene is the responsibility of the whole health care team in order to achieve the best possible results. Balanced with this must be the needs of individuals, as well as the team as a whole ,and of course most importantly the needs of the patients to be protected and to have justified trust in staff, in order that, working together the best possible outcome for all those concerned can be achieved. Appendix 1 Methodology The method used was in the first instance to conduct a literature search using key words and phrases such as ‘cross infection’, ‘hand washing’, skin pathogens’, ‘hand hygiene’, ‘hand washing policies’ etc. This literature was then analysed and discussed. Future practice was considered and suggestions made for possible changes including question to be discussed. References Bellis, M., History of the Microscope, About,.com, available from http://inventors.about.com/od/mstartinventions/a/microscope.htm, accessed 21st October 2010. Boyce, J.M., Pittet, D. (2002)Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practice Advisory Committee and the HICPA/SHEA/ APIC/ IDSA Hand Hygiene Task Force. Infection Control Hospital Epidemiology 23: 12 (suppl), S3-40. Case,C. Hand washing, Access Excellence Classic Collection, available from The National Health Museum, http://www.accessexcellence.org/AE/AEC/CC/hand_background.php accessed 21st October 2010 Coward,J. et al, November 2009, Developing ward accreditation to improve infection control practice, Nursing Times.net, available from http://www.nursingtimes.net/nursing-practice-clinical-research/specialists/infection-control/developing-ward-accreditation-to-improve-infection-control-practice/5008245.article , accessed 22nd October 2010 Delaney,L. and Gunderman,R, January 2008, Hand Hygiene, Radiology 246, 15-19, available from http://radiology.rsna.org/content/246/1/15.full accessed 21st October 2010 Doebelling, B. et al, 1992, Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units, The New England Journal of Medicine, volume 327, 88:93, available from http://content.nejm.org/cgi/content/abstract/327/2/88 accessed 22nd October 2010 Gardener, J.F., Peel, M.M. (1996)Introduction to Sterilization, Disinfection and Infection Control (2nd 3dn). Melbourne: Churchill Livingstone. Hand Washing Campaign, Scottish Government , available from http://www.washyourhandsofthem.com/home.aspx, accessed 22nd October 2010 Holyoake, D., September 2010, The Awkward Feeling campaign: confronting poor hand hygiene to improve handwashing, Nursing Times.net available from http://www.nursingtimes.net/nursing-practice-clinical-research/specialists/infection-control/the-awkward-feeling-campaign-confronting-poor-hand-hygiene-to-improve-handwashing/5018961.article accessed 22nd October 2010 Jeanes, A, 2003, Improving hand hygiene compliance, Nursing Times.net available from http://www.nursingtimes.net/nursing-practice-clinical-research/improving-hand-hygiene-compliance/205394.article accessed 22nd October 2010 Jeanes, A., October 2004, Handwashing: what is the best solution? Nursing Times.net available from http://www.nursingtimes.net/nursing-practice-clinical-research/handwashing-what-is-the-best-solution/199740.article accessed 22nd October 2010 Koo,I. , Evolution of personal hygiene, Infectious disease, About.com, August 2008, available from http://infectiousdiseases.about.com/od/prevention/a/history_hygiene.htm , accessed 22nd October 2010 Louis Pasteur ( 1822-1895), available from http://www.zephyrus.co.uk/louispasteur.html accessed 21st October 2010 McCormick R, Buchman T, Maki D., Double-blind, randomized trial of scheduled use of a novel barrier cream and an oil-containing lotion for protecting the hands of health care workers, American Journal of Infection Control Volume 28, Issue 4, Pages 302-310 (August 2000), available from http://www.ajicjournal.org/article/S0196-6553(00)07195-9/abstract accessed 21st October 22, 2010 Rosner ,F., 1965,The Hygienic Principles of Moses Maimonides, The Journal of the American Medical Association, 194(13):1352-1354, available from http://jama.ama-assn.org/cgi/content/summary/194/13/1352 accessed 21st October 2010 Teare, L.,March 1999 Handwashing; A modest measure-with big effects, British Medical Journal, editorial, available from http://www.bmj.com/cgi/content/full/318/7185/686 ( accessed 21st October 2010 Tibballs J. Teaching hospital medical staff to hand wash, Medical Journal of Australia. 1996;164:395–398. United Kingdom National Audit Office , February 2000, The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England, available as a pdf file, accessed 22nd October 20120 Read More