Issue 11 / 28 March 2011

THE ability of unwashed medical hands and equipment to transmit disease from one patient to the next was a 19th century discovery.

So it is puzzling that, 150 years after Hungarian physician Ignaz Semmelweis discovered that the puerperal fever killing his obstetric patients was actually transmitted to them by their doctors, infection is still the number one complication of hospital admission in Australia.

Many, perhaps most, of the estimated 200 000 cases of hospital-acquired infection in this country each year would be preventable if basic control procedures were followed.

The fact that the federal government has seen the need to set up a National Hand Hygiene Initiative and that the World Health Organization has a similar global one makes it pretty clear that these procedures are lacking.

A study of US trauma patients now reveals something of the toll that hospital-acquired infections are taking in that country.

The mortality risk for trauma patients who developed sepsis was six times higher than for those who did not acquire an infection during their stay. For other hospital-acquired infections in this same patient group, the increase in mortality risk was between 50% and 100%.

There was a financial impact too: patients who acquired infections stayed about twice as long in hospital, incurring double the in-patient costs.

Infectious disease specialist Professor Frank Bowden knows only too well that trying to persuade clinicians to comply with hand hygiene rules can be about as successful as telling a teenager the internet is only for homework.

Professor Bowden, professor of medicine at the Australian National University, hopes data identifying the costs of poor infection control will help to change hospital practices that have become complacent about the issue.

Although hospitals have policies about hand hygiene, most have no mechanisms to ensure they are followed and no way of punishing non-compliance, he says. On top of that, power hierarchies within hospitals make it very hard for junior clinicians — let alone patients — to speak out for infection control.

“I am constantly amazed by the insouciance of my colleagues when it comes to infection control…,” Bowden writes in a forthcoming book. “Adoption of hand antisepsis is often thwarted by the intransigence of senior and influential clinicians.”

And what does he believe it will take to change things?

“Once it becomes clear to the patient population in general that there is a clear link between the behaviour of their medical attendants and the risk of them contracting an infection while in hospital, it is only going to take one high-profile case of a patient suing a hospital for the climate on hygiene to change.”

Let’s hope it doesn’t come to that.

Jane McCredie is a Sydney-based science and medicine writer, and a part-time publisher with NewSouth Books.

Disclosure: Frank Bowden’s book, Gone Viral, will be published in July by NewSouth Books where Jane McCredie is employed.

Posted 28 March 2011

13 thoughts on “Jane McCredie: Hands up for infection control

  1. Rick says:

    Junior’s comments are very telling:
    No amount of university instruction or understanding of the principles is going to help, if there is no understanding of what is happening in the workplace; overburdened clinicians cannot fix the problem (of hand antisepsis is only a part).
    As with many issues related to safety and quality, if the whole systems issue of infection control on the wards is not properly analysed and then properly supported, then it cannot be fixed. Telling Junior to keep his hands clean, and then expecting him to behave like a circus juggler and navigate a gauntlet of infectious traps on rounds is a modern medical farce …
    BTW: Semmelweis was run out of two hospitals for promoting his view on hand antisepsis, and eventually committed (with his wife’s and colleague’s cooperation) to an insane asylum where he died of disseminated sepsis. (Not a lot has changed in NSW hospitals …)

  2. Kylie Fardell says:

    Regarding one of the above posts about alcohol rubs versus soap and water, I thought the hand rubs were not as effective as good old soap for killing spores, and specifically weren’t recommended for organisms such as Clostridium?
    Agree with above comment – I’ve not heard anyone disparage the importance of hand hygiene; it’s always remembering it that is more likely to be the problem. Having rubs at the foot of each bed is very helpful.

  3. Junior says:

    As a relatively recent graduate of an Australian medical school I have to say the importance of handwashing/hand anti-sepsis was very much emphasised throughout our curriculum and I have never encountered any resistance from anyone in the work place towards proper handwashing. Never have I seen a senior (or junior!) clinician actually disparage the process of handwashing or use of alcohol rubs… many of us, in the rush to get the job done, might forget to do it 100% of the time but everyone is contrite and looks appropriately sheepish if reminded. I think the bigger barriers to handwashing and antisepsis are institutional and related to resources (or lack thereof) and lack of practical analysis of how to make “the job” of being a ward-based clinician work more safely and effectively. There are plenty of stupid practices out there helping to spread bacteria between patients… for example the tradition whereby the most junior member of the rounding team is expected to carry a pile of metal files while frantically trying to catch what is being said by The Boss so as to scribble it down (while answering a pager) on a well thumbed page within The Notes (which has also been handled by every member of clinical staff on the ward) with no surface to lean on except the MRSA-colonised patient’s bed table covered with the remnants of their last meal, several sputum cups and a very likely non-functioning pump pack of alcohol hand rub! Things like making sure there are hand pumps at the end of EVERY bed and at EVERY doorway would help, as would having a moveable file trolley or table for doing rounds. And even more important, stethoscopes (of some degree of functional quality!) that are kept at the patient’s bedside! And while I am at it, I have never seen anyone cleaning a bloodpressure cuff in between each patient on a nursing “Obs” round…?

  4. Matthias Maiwald says:

    Regarding some of the previous posts. First, yes, alcohol-based hand antisepsis needs to be done correctly to kill germs sufficiently. A tiny squirt is not enough. Some knowledge is required that there needs to be a sufficient amount (WHO: a palmful) and that all hand and finger surfaces need to be covered by the rubbing (same applies to handwashing, by the way). Second, no, alcohol-based hand antisepsis is not causing more skin problems on hands than handwashing. Quite to the contrary, multiple studies have now shown that alcohol-based hand rubs (commercial ones contain emollients, i.e. re-fatting and moisturising additives) are actually much gentler to hands than handwashing. Both are issues where some knowledge rather than just the behavioural approach (“just tell them to do it”) would be helpful, as pointed out in my previous posts. But that is the approach to infection control teaching currently taken at a number of Australian medical schools (also evidenced by John Stokes’ post). On a pointed note (please excuse the comparison), I am sure that one could train an ape in a zoo to do hand hygiene after every contact with the zookeeper. However, the ape will not understand the theoretical underpinnings of this. I will provide another example, distinct from hand hygiene. This is pre-surgical skin antisepsis. This is important to prevent infections caused by introduction of skin microorganisms into the surgical site. Many Australian surgeons slosh on the disinfectant, wait for less than 30 sec, then start cutting. This is putting patients at serious risk of infection. The requirement is for a contact time of the disinfectant on skin of “at least 2 min, but preferably 5 min” (Infection Control Manual, College of Surgeons). The underpinning of that requirement is that any disinfection process is a time-dependent reaction and no disinfectant kills immediately. This is part of the biological and physico-chemical principles of disinfection processes and is called a “time-kill-curve”. If people do not know about these things, at least in principle, then I would argue it is much less likely that they will follow this in practice. That is what I mean with the ape comparison above and the criticism of the approach to teaching at medical schools.

  5. Richard Middleton says:

    P.s Doesn’t excessive washing with alcohol washes dry the skin, leading to cracking and therefore increase the number of hiding places for bugs?

  6. Richard Middleton says:

    It is shameful that such a simple measure as hand washing are so neglected and with such seriously consequences.
    However, as to why?
    I would suggest that one major reason may be found in the persons of the various so called infection control nurse specialists.
    This is another area that has been cornered by our nurse colleagues. It is an increasing irritation that some of them would rather go around telling doctors to do this and that, very often without any really clear and validated peer reviewed evidence to back it up, than get their hands dirty on real patients.
    Asked why this or that should be done instead of that or this and they often obfuscate or point to some ‘committee’ or little known low circulation self published pamphlet from various overseas nurses with impressive sounding letters after their name, who have somehow come up with an idea, a new ‘recommendation’ based upon their personal strenuous research. Again, if one takes the time to follow up any references that might be proffered, there is a curious circularity, a self referential nature to them.
    Really important information and ideas will tend to be ignored along with the nonsense and fluff.

  7. Anon says:

    Great Comment and good replies
    Handwashing with soap is OK. It maybe isn’t best but better than nil! Personally I hand wash and use alcohol. I doubt the commonly used quick squirt or two of alcohol is enough to kill most bugs on the hands.
    On a quick reading of the posts – I didn’t see anyone mention about hospital cleaning. I have been working in various rural hospitals in one Australian state, and the general cleaning is very inadequate. One hospital only cleaned the floors daily, with extra cleaning being only a quick clean of trolleys and beds in ED nursing staff. My comments were not appreciated by the senior (non-medical) management where we were seeing 6-8 cases of impetigo daily in a small hospital, resistant Staph being grown on swabs and cleaning was inadequate. Soap and detergent more needed than antibiotics!
    Commonly handled areas aren’t at all or very infrequently washed – like hospital front door handle after hours. People are incredulous that I bother to be concerned……
    My comment on training medical students – it has to be mainly hospital based with introduction theoretically with some lectures. In medical school and afterwards. As we learn proper use antibiotics and other skills clinically so it should be with this.
    Everyone needs to lift their game. There is a urgent need to lessen the amounts of antibiotics prescribed generally in Australia, to slow the growth of antibiotic resistance.

  8. Matthias Maiwald says:

    John Stokes’ response is appreciated. But again it emphasises on handwashing. As mentioned in my original post, handwashing is important, but clearly only of secondary importance when it comes to hand hygiene in healthcare settings. There is a clear call by the WHO (Hand Hygiene Australia are in line with this) that the primary method should be hand antisepsis with alcohol-based hand rubs, not handwashing. Placing the primary emphasis on handwashing is teaching medical students the wrong thing. Also, as mentioned in my original post, there is now an emphasis at a number of Australian medical schools, like the one described by John, to teach students the importance of compliance with hand hygiene in a practical context (i.e. in clinical practice situations). The approach by James Cook Uni is definitely laudable. However, this is a focus almost exclusively on behavioural issues (“tell them to do it”), but there is almost nothing in terms of teaching students any understanding of the basics and underpinnings of infection control. If there were such teaching, then students would understand the difference between handwashing and hand antisepsis and why exactly hand antisepsis is the method of choice. That means students just learn by imitating things in practice situations, not by truly understanding things. As mentioned, while there is a current emphasis on hand hygiene in practice situations at a number of Australian medical schools, there is precious little teaching of anything else in infection control other than hand hygiene, let alone any understanding of the theoretical underpinnings of infection control.

  9. John Stokes says:

    Mathias and others
    Thought you might like to know that hand washing and techniques are part of the James Cook University School of Medicine Curriculum from year one and in every exam from year one students get marks for correct hand washing in their practical exams. In their practical bedside teaching some of us even teach how students might influence hand hygiene behavior of their seniors by various communication skills and one activity in year 4 is an observational activity regarding hand hygiene in hospitals (both private and public). You are right though many doctors consider it unimportant to do and less important to teach. The problem though is in the workplace and not in the medical schools.

  10. Matthias Maiwald says:

    I would like to raise two points, as a response to the article as well as to the (so far) two posts. First, Semmelweis did not promote handwashing. One of his major findings was that handwashing with soap and water (that was well known at the time) was not as beneficial in preventing infections than hand treatment with chlorinated lime (which we know today is a method of hand disinfection or hand antisepsis rather than washing). In (modern) line with this, the WHO Global Patient Safety Campaign and the WHO Guideline on Hand Hygiene 2009 is promoting hand antisepsis with alcohol-based handrubs as the standard of care; handwashing with water and soap is still important, but of secondary importance. The Hand Hygiene Australia Campaign is also in line with the WHO campaign about this. Second, the situation concerning infection control in Australia is actually more problematic than what Ms McCredie’s article describes. There is very little (close to none) teaching about infection control in Australian medical schools. I am aware of an example of an Australian medical school that had 2 teaching sessions on anything related to infection control throughout the entire curriculum, and after intervention from a lecturer with interest in the topic, the school increased this to a ‘whopping’ 4 sessions, that is for the entire time before they graduate. As far as I know, this medical school is not an exception. Currently there are initiatives underway in several medical schools to get medical students compliant with hand hygiene, but there is still precious little teaching that would provide the students with an underpinning and an understanding of the principles of infection control and especially other infection control measures besides hand hygiene.

  11. Rob the Physician says:

    Resistance to hand washing…is it ? or perhaps an arrogance that we as a profession think we have progressed beyond the basics and are too educated to worry about the mundane.
    Whatever..!it is about time clinicians at all levels start “walking the walk AND talking the talk” in humility…

  12. Howard Kingston says:

    We as a profession are often resistant to hand washing and it is hard work to do it after every patient in a busy schedule. However I well remember my professor of surgery having to insist, on ward rounds, that his staff wash their hands before putting them in a patient’s mouth – even when a finger had just been withdrawn from a rectum!

  13. John Stokes says:

    I am amazed that senior doctors will still ignore guidelines about hand washing and continue to set bad examples for our students and young doctors. Most still do not understand that Semmelweis discovered that hand washing decreased mortality. When you ask why we wash hands no one ever answers “to save lives”. You get every other answer but few remember Semmelweis made his discovery about death rates before we understood microbiology, nosocomial infection or transmission mechanisms. The important issue to keep pushing is that doctors and hospital workers can be “vectors of death” if they refuse or forget to wash their hands between patients. The other issues are no doubt important, costly and cause great morbidity but in reality doctors and students should not be killing patients. So perhaps the first sentence should have read “The ability of unwashed medical hands and equipment to kill patients was a 19th century discovery.”

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