First do no harm…role-modeling of hand hygiene

8 December 2014

Hand hygiene nurse champion LOUISE DAWSON recently reminded a clinician to carry out hand hygiene before cannulating her. The clinician's response was a cursory hand rub and a comment that the evidence didn't stack up for hand hygiene in most cases anyway.  Dawson wonders whether it will take more superbugs and increasing antibiotic resistance before some finally get the hand hygiene message.

The practice of hand hygiene in healthcare is certainly not new. However getting all healthcare workers to consistently carry out hand hygiene at patient  'point of care' remains an ongoing challenge.   

Slowly but surely though, the patient safety message is getting through - particularly within the public hospital system where constant vigilance and reporting of hand hygiene performance ensures a strong focus on hand hygiene.

I believe two of the most positive actions to improve our public hospital hand hygiene over the last five years has been the nationwide district health boards' hand hygiene improvement programme (Hand Hygiene New Zealand, HHNZ) and the widespread use of alcohol-based hand rub, (ABHR), particularly at the point of care.  ABHRs ease of use, accessibility, quick drying, relatively low-cost and limited ill-effects on hands, has revolutionized the ‘right time, right place’ uptake of hand hygiene practice in hospitals.

But despite these two actions there are still highly-educated healthcare workers who do not believe that hand hygiene in all clinical care is a reasonable request to reduce the risk of healthcare associated infections.

I am currently part of a community-based University research project and recently found myself, alongside many others, being cannulated for a series of blood tests. The doctor gathered the necessary equipment and reached for her gloves. I asked if she would please use the hand rub, located very closely, before she gloved and cannulated me.  

Her response was to perform the scantest of hand hygiene  - just 2-3 quick swipes of palm and finger interface - and her hands were still wet when she pulled on the gloves. She then proceeded to tell me that hand hygiene really wasn’t necessary as she was not aware of any evidence to support hand hygiene practice making any difference in a clinical community setting ; the only exception being when dealing with immuno-compromised patients in an acute care setting. The doctor then proceeded to put ABHR on her gloved fingertips – another non-evidenced based practice – ­before carrying on with the cannulation.

 I sighed and wondered how 150+ years post-Semmelweiss* - and with superbugs rapidly gaining momentum – can we have a highly educated medical practitioner (PhD – she told me) who only halfheartedly believes in the benefits of hand hygiene.

I also witnessed her laboratory colleague receiving faecal and urine samples, as well as decanting fresh syringes of blood into test tubes wearing the same pair of gloves the whole time.

Then – still wearing those same gloves - he approached me to take blood from my cannula.  The doctor’s words were still ringing in my ears  - there's no evidence to support hand hygiene in a community setting –but I found them far from reassuring.  Nope, I just couldn’t let him touch me.  After repeating to him what I had seen him do with those continuously gloved hands I asked him to remove the gloves, perform hand hygiene and put on a fresh pair of gloves. He smiled very sweetly and obligingly and said 'yes, you are right, of course I will'. To his credit thereafter he did the same every time he took my blood.

When a highly educated senior practitioner doesn't model the best hand hygiene practice, and contradicts 150+ years of evidence, is it any wonder public hospitals struggle to get sustained improvement in hand hygiene in public hospitals let alone community settings?

In the end it will be the increasing resistance to antibiotics and the fear of receiving ever more life threatening infections that will see the next big push in improving national and international hand hygiene practice. So when all else has failed, people will ask, 'why not just clean your hands?'

 * Hungarian physician Dr Ignaz Semmelweis (1818 – 1865) is now acknowledged as a pioneer of antiseptic procedures after postulating the theory in 1847 that handwashing with chlorinated lime solutions would reduce maternal mortality from purpureal fever.  He was sadly deemed a madman by his peers.