Out, damned spot! Out, I say!

1 October 2014

MARGARETH BROODKORN takes a look at the chequered history of hand washing and asks whether today's health professionals have progressed that much?

Margareth BroodkomThe paranoid subconscious of the sleepwalking Lady Macbeth in Shakespeare’s Macbeth may have some relevance to the challenges of hand hygiene compliance with health professionals.

Lady Macbeth’s hallucinations of blood on her hands and paranoid response could be a useful analogy for health professionals not washing their hands and the subsequent risk to the patients they care for.

Attempts at minimising cross-infection though effective and appropriate hand hygiene practice has been a longstanding issue within the health sector, stemming back as far as the 1800s. Hungarian physician
Dr Ignaz Semmelweis (1818–1865) – while later acknowledged as an early pioneer of antiseptic procedures – was sadly deemed a madman by his peers.

Regarded as the ‘saviour of mothers’, Semmelweis suggested that the incidence of puerperal fever could be drastically reduced by the use of hand disinfection in the field of obstetrics. While working in a Vienna hospital, he noted that doctors’ wards had three times the mortality of the midwives’ wards and postulated the theory of washing with chlorinated lime solutions in 1847.

Despite various publications showing his hand washing theory reduced mortality to below 1 per cent, his observations conflicted with the medical establishment of the day and were rejected by the medical community. One strident opponent to the idea that doctors could be transferring puerpereal fever between their patients was American obstetrics professor Charles Delucena Meigs, who reportedly said “doctors are gentlemen, and gentlemen’s hands are clean”.

It wasn’t until Louis Pasteur’s germ theory of disease offered what was deemed a more scientific explanation to Semmelweis’s work that he was recognised. Unfortunately, and ironically, Semmelweis died at the age of 47 of septicaemia after being admitted to an asylum.

In 1859, Florence Nightingale stated in her Notes on Nursing that “every nurse ought to be careful to wash her hands very frequently during the day”. Therefore, it is not a new concept that healthcare workers should be diligent with washing their hands.

Fast forward to 2014 and we ask ourselves how far we have come in adopting a well-proven healthcare intervention? Given that hospital-acquired infections represent some of the most frequent adverse events in healthcare worldwide – and up to 10 per cent of patients admitted to modern hospitals acquire one or more hospital acquired infections – have we progressed that much?

Hand Hygiene New Zealand (HHNZ) maintain that hand hygiene is one of the simplest yet most effective measures in the fight against such infections, making hand hygiene practice a key patient safety issue in New Zealand hospitals. Established in 2008, the Hand Hygiene New Zealand programme promotes the five internationally accepted moments of hand hygiene and aims to reduce healthcare associated infections through adherence to The 5 Moments for Hand Hygiene for every patient every time.

Of course, it goes without saying that health care workers should wash their hands after going to the toilet, after sneezing or coughing into hands, after handling contaminated material and removal of gloves, and before handling food.

The objective of the HHNZ programme is to achieve 75 per cent compliance by June 2014 and 80 per cent in June 2015. Since the first performance data was submitted in October 2012 at 61.2 per cent, steady improvement in hand hygiene performance has been noted across the country. In March 2014, this had risen to 72.6 per cent. Data from the April to June 2014 Hand Hygiene performance report noted a 73 per cent achievement.

The results from hand hygiene audits show that nurses and midwives have responded well to adopting the five moments and role modelling effective hand hygiene practices. Unfortunately, national and local surveys of our medical colleagues paint a different picture of poor hand hygiene practice.

To ensure that effective and hand hygiene is part of everyday ‘business as usual’ practice, leadership is critical in turning this around, given that these surveys show that the hand hygiene practice of doctors is influenced more by their senior colleagues than patient influence. Hand hygiene initiatives such as local champions, hand hygiene campaigns and audits, and various health promotion activities are making a difference, but we need to maintain vigilance in ensuring that a patient-centred care approach in improving effective hand hygiene practice is held as a high priority.

We cannot succumb to the so-called unfortunate Semmelweis reflex, where the common sense and clinically proven practice of effective hand hygiene is ridiculed and rejected as something that is not achievable or reasonable to expect of all health care workers. :


Margareth Broodkoorn is director of nursing and midwifery at Northland District Health Board and a director on the College of Nurses Aotearoa’s board.

The 5 Moments for Hand Hygiene

Moment 1: Before touching the patient or the patient’s surroundings (on entering the patient zone)
Moment 2: Before performing an aseptic procedure
Moment 3: After a body fluid exposure risk
Moment 4: After touching the patient (if leaving the patient zone)
Moment 5: After touching the patient’s surroundings only (if leaving the patient zone).