hand hygiene
By Paul Alper
Major Historical Milestones in Healthcare Hand Hygiene : A High-Level History of Our Most Important Practice for Infection Prevention
Reading Jane Brody ’ s July 12 article “ Why We Should Keep
Washing Our Hands Post Pandemic ”
1 and noting her references to the Jewish and Muslim roots of hand hygiene , it seemed a good idea to reflect on the key healthcare related moments in hand hygiene through the centuries . Here ’ s a look at 12 of them .
The notion that physicians should wash their hands before
1 and after patient contact dates at least as far back as the 1100s when Moses Maimonides wrote , “ I dismount my animal , wash my hands , go forth to my patients ,” and “ Never forget to wash your hands after having touched a sick person .” 2
In April 1847 Ignaz Philipp Semmelweis , a Hungarian physician ,
2 was working in Vienna General Hospital ’ s first obstetrics clinic . This clinic was used for teaching medical students who conducted autopsies as part of their training while a second clinic was only used for the training of midwives who had no contact with cadavers . Semmelweis noted that the mortality rate from puerperal or “ childbed ” fever was 18.3 percent when the physicians attended obstetrical patients directly after performing autopsies . The rates were much lower in the second clinic .
He proposed the practice of washing hands in a solution of chlorinated lime ( calcium hypochlorite ) as a way to “ remove the putrid smell of infected autopsy tissue .” 3 After the hand-cleansing practice was put in place in May , the rates dropped 90 percent to 2.2 percent , 1.2 percent and 1.9 percent respectively in June , July and August , comparable to the second clinic .
While today Semmelweis is known as the grandfather of hand hygiene , his research was at odds with the prevailing opinions held by scientists and physicians at the time and his recommendations were rejected by the medical community at large . Some doctors took offense at the suggestion that they should wash their hands and ridiculed Semmelweis who , in 1865 , experienced a nervous breakdown , was committed to an asylum and , after a beating by guards , died from an infection .
It was common practice until the 1970s for hand soap in
3 healthcare facilities to be available from open-reservoir dispensers refilled from gallon jugs . These dispensers required cleaning between each fill-up that was not likely done with consistency . A start-up company from San Antonio , Texas invented “ bag in a box ” refills – closed , sealed , sanitary refills of hand hygiene products that eliminated most risk of contamination . Today , virtually all healthcare facilities use hand hygiene systems based on sealed refills .
Alcohol-based handrubs ( ABHRs ) were introduced into the
4 healthcare market in the 1980s . At first there was reluctance by infection prevention and nursing leaders to abandon soapand-water handwashing . Use of ABHRs today is the standard for patient care globally and is routinely used for hand hygiene .
It is easy to see a similarity between Semmelweis and early ABHRs . As the German philosopher Arthur Schopenhauer said , “ All truth passes through three stages . First , it is ridiculed . Second , it is violently opposed . Third , it is accepted as being self-evident .” 4
5
Then widely used in healthcare facilities but not generally available to consumers , ABHRs or “ instant hand sanitizers ” as they came to be known , were first widely available to consumers through major retail outlets in 1997 . The first in-store display with a tester pump bottle heralded , “ Try Me ! No Water , No Towel … No Germs !”
The 2002 CDC Guideline for Hand Hygiene in Healthcare Care
6 Settings 5 proclaimed ABHRs with 60 percent to 95 percent alcohol to be the most effective , finally providing guidance on what was already well known and accepted practice , 20 years after their first use .
The World Health Organization ( WHO ) introduced the “ 5
7 Moments of Hand Hygiene ” in 2009 to reduce the risk of healthcare-associated infections ( HAIs ). This has become the standard for most of the world today although the U . S . still primarily uses the “ in-and-out ” standard .
In 2009 the Joint Commission published its monograph
8 on compliance , “ Measuring Hand Hygiene Adherence : Overcoming the Challenges .” 6 While containing a great deal of information on methods to measure compliance ( direct observation , product utilization measurement , patient surveys , video cameras and more ) along with their relative strengths and limitations , this monograph fell short of suggesting specific best practice standards of care .
John Boyce , in his 2017 paper , “ State of the Science
9 Review - Electronic Monitoring in Combination With Direct Observation as a Means to Significantly Improve Hand Hygiene Compliance ,” 7 presented evidence to support the emerging best practice standard of care : electronic monitoring as the preferred method for measuring hand hygiene compliance with direct observation used for coaching , feedback and obstacle identification . Evidence supporting this approach was published by Kelly , et al . in 2016 . 8
Electronic hand hygiene compliance monitoring systems
10 ( EHHCMS ) were first introduced in the early 2000s but the first study linking their use to improved hand hygiene behavior , reduced HAIs and positive economic impact was published in 2016 by Kelly , et al . 9 The study demonstrated a 25 percent increase in compliance , a 42 percent decrease in methicillin-resistant Staphylococcus aureus ( MRSA ) infections and a cost avoidance of $ 670 per bed per year in the first year .