Lady Macbeth had it right: Wash your hands, over and over.
Better Medicine: Do the math on hand-washing
She was obsessed with it. Physicians and healthcare workers should be, too. On any given day patients will suffer 1.4 million healthcare-acquired infections worldwide. And the evidence is uncontestable—hand-washing prevents the transmission of infectious diseases in healthcare settings. Both the World Health Organization and the Centers for Disease Control and Prevention agree that proper hand hygiene is the most important, simplest and least expensive means of preventing healthcare-acquired infections. In addition, it is equally important in combating transmission of multidrug-resistant pathogens. And for those still objecting to the evidence, a recent study has correlated hand-washing efforts with the ultimate outcome measure—survival in the ICU. Researchers at the University of North Carolina found that an initiative to reduce bloodstream infections in the pediatric ICU, with an emphasis on hand-washing in particular, reduced the length of stay for patients in the ICU, reduced the cost of a stay and reduced the mortality rate.
Even with all the evidence, though, getting staff to participate in robust hand-washing efforts has been impossibly difficult. Some improvement has been seen when alcohol rub dispensers are placed strategically in a clinical unit. This might be because it takes less time to "wash" with rub, which can be done as providers walk from room to room, than to stand at a sink and navigate both soap and towel dispensers. Design research has something to add as well; investigators have found that placing sinks at an angle to the patient's bed facilitates hand-washing because they don't require the provider to turn his back on the patient or family members. Other efforts, like signs at the head of the bed, real-time feedback and continuous tracking all help to improve hand-washing compliance.
But in spite of all this, it is still common for baseline data to show physician and staff hand-washing compliance as low as 35% to 50%. The problem may relate to the "burden" of hand-washing on workflow in the clinical setting. Think about it for a minute and do the math. Current recommendations call for the cleansing of hands both before and after seeing a patient. A physician on a clinical unit like an ED will on average see two patients an hour. The ED visit will involve at minimum a visit with the patient on arrival and a visit prior to discharge, though for many complaints there will be more patient assessments to determine responses to therapy or to answer questions, etc. But even assuming just two patient assessments, the ED physician seeing the average two patients per hour, washing his hands before and after each visit, is required to wash his hands an impossible 64 times in an eight-hour shift! This means washing hands approximately every seven minutes for eight hours straight. Is it realistic, doable, sustainable?
The before-and-after hand-washing idea comes from bacteriology studies that have shown MRSA-positive patients have live bacteria on 27% of the surfaces near their care areas. This poses an infection risk for other patients in proximity because the bacteria may be transmitted through healthcare providers. Not surprisingly, the rates of MRSA infection are higher in ward settings with multiple-occupancy rooms. So if hand-washing is next to impossible to sustain, as I have postulated, are there design elements that could be married to process changes that could get us to the same place?
Copper surfaces have been shown to retard bacterial growth. At one hour, MRSA-contaminated surfaces had zero live bacterial counts on a copper surface. Apparently, dry copper causes damage to cell membranes within minutes. It does not cause mutation rates or DNA damage. Copper is almost as effective on viruses; at one hour after contact with copper only 75% of influenza A virus is viable. We are just beginning to understand the antimicrobial properties of copper, but the implications for the building design in healthcare are substantial.
What if healthcare providers could wash their hands before touching a patient, and let the copper do the rest? There might then be more time for physicians and other healthcare providers to do the work that needs doing. Lady MacBeth had it right, but we in medicine need to do the math. There may be innovations afoot that would reduce the required hand-washing by half. These innovations will lead to even better medicine!
Dr. Shari WelchUtah Emergency PhysiciansSalt Lake CityPresidentQuality Matters Consulting
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