Published 12/1/2007
the AAOS Patient Safety Committee

Fight infections: Engage in hand-to-hand combat

Surgeons should lead by example: Follow hand hygiene guidelines

The concept of good hand hygiene is familiar to all healthcare workers, particularly surgeons, who are meticulous about scrubbing before operating. Good hand hygiene, however, should extend beyond the operating theater into hospital rooms and office settings.

The recent surge of media attention to methicillin-resistant Staphylococcus aureus (MRSA) and the arrival of cold and flu season underscore the importance of consistently practicing good hand hygiene. Hand washing with soap and water is common, but alcohol-based hand sanitizers and other antimicrobial preparations are also available for use. An added benefit of hand hygiene is a reduction in absenteeism due to illness, which may help to keep clinics and operating room schedules running smoothly.

Although many resources exist to encourage increased compliance in your institution, the most powerful tool available to surgeons may be leadership by example. Following are some tips and quick statistics on hand hygiene:

  • The main mode of transmission of MRSA to other patients is through human hands, especially healthcare workers’ hands. Without appropriate hand hygiene such as washing with soap and water or using an alcohol-based hand sanitizer, bacteria can spread when healthcare workers touch patients.
  • Clean hands are the single most important factor in preventing the spread of dangerous germs and antibiotic resistance in healthcare settings.
  • The Centers for Disease Control and Prevention (CDC) recommends the use of alcohol-based hand rubs by healthcare personnel for patient care because they significantly reduce the number of microorganisms on the skin, are fast acting, and cause less skin irritation than soap and water.
  • More widespread use of products such as alcohol-based hand rubs, which improve adherence to recommended hand-hygiene practices, will promote patient safety and prevent infections.
  • In 2004, poor compliance with hand-hygiene requirements was recognized as potentially contributing to the inability to control MRSA transmission. In an Australian study, use of alcohol chlorhexidine handrub was mandated for existing and visiting staff to the intensive care unit (ICU), and its use was actively promoted by all ICU staff. Following the implementation of the campaign, the average monthly acquisition of MRSA in the unit dropped from 15.2 patients per 1000 occupied bed days (OBD) to 3.2 patients per 1000 OBD.
  • At another Australian hospital, a series of interventions—including the introduction of an antimicrobial hand-hygiene gel to the ICU and a hospital-wide MRSA surveillance feedback program that used statistical process control charts, but not active surveillance cultures—was implemented over a 2½ year period. The interventions resulted in a hospital-wide reduction in new patients with MRSA; the pre-intervention rate of 3.0 cases per 100 patient admissions dropped to 1.7 cases per 100 patient admissions during the intervention period.

Transmission of pathogens
According to the CDC, the number of organisms (S. aureus, Proteus mirabilis, Klebsiella species and Acinetobacter species) present on intact areas of the skin of certain patients can vary from 100/cm2 to 106/cm2.

Documented studies have shown that healthcare workers may contaminate their hands (or gloves) merely by touching inanimate objects in patient rooms.

One study found that S. aureus could be recovered from the hands of 21 percent of ICU personnel and that 21 percent of physician carriers and

5 percent of nurse carriers had more than 1,000 colony-forming units on their hands. Serial cultures revealed that 100 percent of healthcare workers carried gram-negative bacilli at least once, and 64 percent carried S. aureus at least once.

Adherence to hand hygiene
Adherence of healthcare workers to recommended hand-hygiene procedures has been poor, with mean baseline rates of 5 percent to 81 percent, and an overall average compliance rate of 40 percent.

Figure 1 illustrates the hand-hygiene compliance rate among healthcare workers during a study conducted at two hospitals in Quebec. Compliance ranged from 32 percent to 81 percent over a 5-year period. Evidence revealed fluctuating compliance patterns for the duration of the study. Hand-washing opportunities were categorized by hospital ward, type of personnel, isolation precautions, and type of care procedure. Hand washing and alcohol-based gel use methods, including friction time, were also recorded.

Healthcare workers are often in the spotlight, encouraging the public to make hand washing part of their daily routine. Even school children are getting involved in the hand-hygiene campaign. During National Hand Washing Week, held the first week of December, students perform science projects and act out skits on the subject, and even vie for the title of “Hand Washing Champion” by keeping a record of who washes their hands the most.

The AAOS Patient Safety Committee is chaired by Robert L. Brooks, MD. Questions can be directed to staff liaisons Katherine Sale (sale@aaos.org) or Juleah Joseph (joseph@aaos.org).