By these members of the Nurses Leadership Council, a group of nurse educators who advised the American Chemistry Council’s Chlorine Chemistry Council for several years in the early 2000’s: Nettie Birnbach, RN, EdD, FAAN; Ann W. Burgess, RN, DNSc, CS, FAAN; Willa M. Doswell, RN, PhD, FAAN; Lucie S. Kelly, RN, PhD, FAAN; Donna A. Peters, RN, PhD, FAAN; and Marlene R. Ventura, RN, EdD, FAAN

Nurses use their hands to perform countless deeds that heal and comfort. Deftly and gently, they connect catheters for the critically ill. Their reassuring grip calms tense mothers in childbirth. And their steadfast clasp brings silent dignity to patients experiencing peaceful death.  Nurses use their hands constantly to dispense expert care. Ironically, in their rush to meet patients’ needs, today’s nurses may unwittingly be dispensing something else to patients via their hands: disease-causing germs.

In 1847, the Vienna General Hospital was the scene of a landmark medical discovery: An obstetrician, Dr. Ignaz Semmelweiss, realized that patients treated by doctors in one ward were much more likely to die of puerperal (childbed) fever than those treated by midwives in another ward. Semmelweiss noted that doctors were administering to patients directly after performing autopsies on victims of puerperal fever, sometimes without washing their hands or changing their clothes. Midwives, he realized, never performed autopsies.

When Semmelweiss’s supervisor died of puerperal fever after cutting his hand with a scalpel used during an autopsy, the doctor concluded that “morbid particles” on scalpels, hands, and clothing were responsible for spreading the disease. He began insisting that doctors wash their hands with a chloride of lime solution and change their clothing between performing autopsies and examining patients.1   

The experiment bore fruit: When doctors followed Semmelweiss’s regimen, the mortality rate from puerperal fever in their ward plummeted. Germs, the “morbid particles” on their hands, were being defeated by a chlorine disinfectant. Unfortunately, Semmelweiss failed to convince his superiors of the link between handwashing and disease. He was derided by his colleagues and fired. Infection control through handwashing would be stalled for another generation until the published works of Louis Pasteur and Joseph Lister advanced the germ theory of disease—the recognition that microscopic organisms may be a cause of disease.

 

Don’t Give Germs a Ride

Understanding that the causes of many illnesses are microscopic organisms that take up residence in the human body—and that these agents may be transmitted by contact with body fluids or skin—enables us to wage war against infectious disease. And when it comes to spreading infectious disease, human hands are to germs what mass transportation is to city dwellers: a convenient mode of travel.

The Centers for Disease Control and Prevention (CDC) says that handwashing is “the single most effective way to prevent the transmission of disease.” Yet, reports indicate healthcare workers adhere to handwashing guidelines less than 70% of the time. Insufficient handwashing by healthcare workers is a major factor in the development of hospital infections in patients.2 It’s estimated that one in 10 hospital patients acquires an infection as a direct result of being hospitalized.3

Do nurses realize the extent to which they fall short of the mark in hand hygiene? Apparently not. Studies show nurses overestimate their observance of handwashing guidelines. And the busier the nursing unit, the lower the level of attention to hand hygiene, regardless of nurses’ internal motivation to conform to recommendations. These findings suggest further study is needed to reveal the relationship between work intensity and the ability of nurses to function safely.2

In an attempt to address the critical need for improved hand hygiene among healthcare workers, the CDC introduced guidelines on the use of alcohol hand rubs last fall at the Infectious Diseases Society of America’s 40th annual meeting. According to CDC Director Julie Gerberding, MD, MPH, the use of alcohol hand rubs is an expansion of a comprehensive approach to hand hygiene that also includes washing with soap and water for removal of unsightly debris and gloving during contact with blood and other body fluids.4

According to Steve Solomon, MD, acting director of the CDC’s healthcare quality promotion division, alcohol hand rubs “should help promote hand hygiene because they are much more accessible than sinks, take less time to use and cause less skin irritation and dryness than many soaps.”5

John Boyce, MD, of the Society for Healthcare Epidemiology of America and chief author of the guidelines, points to numerous studies concluding that alcohol-based products are more effective at reducing bacterial counts on hands than plain soap and, in most cases, more effective than antimicrobial soaps.4 Alcohol rubs are also better tolerated by the skin than soap and water. 6 And the availability of alcohol-based handrubs was found to improve compliance with hand hygiene in ICUs.7

Nothing to Lose, Plenty to Gain

Consider this: Over the course of a normal workday, in numerous instances in which proper nursing care calls for thorough handwashing, nurses choose whether to wash their hands.  In choosing not to do so, they automatically make another choice—to risk the spread of infection.  Where is the advantage to a caregiver in forgoing hand hygiene to save time, only to increase the risk of infecting themselves and their families? What is the net gain if the side effect is increasing costly hospital infections?

Nurses routinely check patient identification wristbands before administering medication; they know that dispensing the wrong drug to patients could be disastrous. Like hand hygiene, this is a rather mundane, low-tech, but eminently necessary precaution. If proper hand hygiene becomes as habitual an activity among nurses as patient identification checks, hospital infections might decline and nurses would have incorporated another significant measure of personal safety into their profession. The hands of the nurse—the hands that heal—would no longer dispense unintended harm.

AHA Advisory on Safe Use of Alcohol-Based Hand Rubs

Although the CDC advises that alcohol-based hand rubs may be a better option for hand hygiene than hand-washing, many healthcare facilities have run into problems installing hand-rub dispensers — national and local fire codes restrict the location and use of these types of flammable liquids.

The American Hospital Association (AHA) and the Centers for Disease Control and Prevention held a meeting recently about the effectiveness of alcohol-based hand rubs and fire safety issues related to their use, and has issued a Quality Advisory to member hospitals summarizing their findings. A study commissioned by AHA’s American Society for Healthcare Engineering found that hand-rub dispensers could be safely installed in corridors as long as the volume of the hand rub was 1.2 liters or less, and the dispensers were not installed too closely together or over carpeting.

Healthcare and fire safety groups attending the meeting agreed to take steps to revise the national fire codes or obtain exceptions to permit safe placement of the dispensers in readily accessible locations. The AHA advisory suggests hospitals consider placing hand-rub dispensers in appropriate areas, such as patient rooms, but not in exit corridors or next to sinks. It also suggests that hospitals work with local fire marshals to ensure installations meet local fire codes.

References

1 Dr. Semmelweiss Was Right: Washing Hands Prevents Infection. Water Quality and Health website. Available at: www.waterandhealth.org/newsletter/new/feb-1998/right.html. Accessed September 25, 2003.

2 O’Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control. 2001;29(6):352-360.

3 Tilton D. Nosocomial infections: diseases from within our doors. Accessed September 25, 2003.

4 CDC Releases New Hand Hygiene Guidelines for Healthcare Settings. CDC website. Accessed September 25, 2003

5 CDC releases new hand-hygiene guidelines. CDC website. Available at: www.cdc.gov/handhygiene/pressrelease.htm. Accessed September 25, 2003.

6 Winnefeld M, Richard MA, Drancourt M, Grob JJ. Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use. Br J Dermatol. 2000;143(3):546-550.

7 Hugonnet S, Perneger TV, Pittet D. Alcohol-based handrub improves compliance with hand hygiene in intensive care units. Arch Intern Med. 2002;162(9):1037-1043.

Copyright 2003. Nursing Spectrum Nurse Wire. All rights reserved. Used with permission.

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