The third inconvenient truth according to
Gould and Purssell , et al . ( 2022 ) is that the patient zone is not a fixed entity , because as patients move between clinical areas on the same ward and to non-clinical areas , they carry their microbiota with them . The researchers say that seeing the patient zone as “ a single , homogenous area oversimplifies the complexity of healthcare environments .”
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contact within it . Unfortunately , adherence at these moments is often low , and even if hand hygiene is undertaken it may not be thorough enough to remove all pathogens from the hand surfaces , especially if health workers are busy and hand hygiene episodes are rapid and perfunctory .” They add that using portable equipment such as vital signs-monitoring devices between patients and other items such as tablets carried into the patient zone present additional risks because decontamination is not feasible with constant movement across zones .
Although it will require resources and funding , the researchers suggest introducing self-disinfecting surfaces and equipment , as well as increasing the frequency of cleaning in clinical and non-clinical areas , especially high-contact areas . They also recommend introducing chlorhexidine gluconate into the formulations of handrubs used in clinical areas .
The authors emphasize the importance of environmental cleaning , and as McKnight comments , “ I think there ’ s a lot of interesting science here . On one side , some of the emergent work is worrying – I ’ m thinking here of Crook ’ s work on sinks harboring resistant pathogens . But I also think there are reasons to be hopeful , as materials science is offering new ideas all of the time . That said , while I ’ m a proponent of innovation , I do think we should continue to push for careful , evidenced-based practice . Being from the UK , I was surprised at how some hospitals can still be sold on fairly wacky ideas , and it is important that an evidence base is established for putative solutions as sales people are extremely good at cherry-picking studies .”
Strategies to Address Transmission Risks From Lack of Hand Hygiene
Because adherence to the Five Moments cannot prevent all risks of transmission , Gould and Purssell , et al . ( 2022 ) suggest :
• Implement hand hygiene dispensers at hospital , clinic and ward entrances with prompts , monitoring and national signage
• Introduce a stochastic approach to hand hygiene programs and audit at agreed “ set points ”
• Refresh hand hygiene training to reflect the stochastic approach
• Introduce self-disinfecting surfaces and equipment
• Introduce chlorhexidine gluconate into handrubs used in clinical areas
• Increase frequency of cleaning in clinical and non-clinical areas , especially high-contact areas
Gould and Purssell , et al . ( 2022 ) unequivocally state that “ Unless health workers conceptualize the patient zone as intended by Sax et al . ( 2007 ) there may be risk of transmission . The way that hand hygiene audit is undertaken is known to drift over time within organizations according to local interpretation . It is likely that health workers ’ interpretations of the Five Moments may be subject to drift in the same way .”
The challenge of auditing under the Five Moments framework , these experts reason , is that routine audits are usually restricted to patient-care areas , but disposal of body fluids takes place away from
If the Five Moments are applied , crossinfection should be avoidable providing hand hygiene is undertaken before the health worker enters the patient zone or initiates contact within it . Unfortunately , adherence at these moments is often low , and even if hand hygiene is undertaken it may not be thorough enough to remove all pathogens from the hand surfaces , especially if health workers are busy and hand hygiene episodes are rapid and perfunctory .”
the bedside . As a result , they say , “ data for Moment 3 ( after risk of exposure to blood and body fluids ) is often missed . Many hand hygiene opportunities exist outside the patient zone , are not encapsulated within the Five Moments and are omitted from hand hygiene audits ( after handling potentially contaminated equipment in utility rooms ). Health workers not directly attached to wards are frequently excluded . Observation of activities within the patient zone is frequently incomplete because the vantage is poor and bedside curtains obscure clinical activities . Visitors to healthcare facilities are often excluded , although they may contribute to care and their hands may be contaminated by pathogens responsible for HCAI . Adaptation is necessary before hand hygiene audit tools can be used in settings other than wards , but little guidance is available .”
McKnight and his co-authors acknowledge that their paper upsets the status quo ; however , he says despite a lack of feedback from healthcare workers on their five inconvenience truths , “ If you believe you already have a perfect solution or even a near-perfect solution , there isn ’ t much space for experimentation or even mild criticism . We didn ’ t receive any feedback from clinicians , but I hope we struck a chord with some of the unfortunate people who have it as part of their job description to bring about hand hygiene perfection in facilities not built for this , that healthcare workers often have better things to do ( literally ).”
McKnight and his co-authors say that the Five Moments need to be updated to meet contemporary needs in conjunction with other technologies and emphasize that this post-pandemic period is the perfect time to explore new or revised frameworks : “ Introducing new hand hygiene interventions fits well alongside the organization-wide changes introduced to prevent the spread of SARS-CoV-2 and the part played by the infection prevention teams who spearheaded them .” They add , “ Before the COVID-19 pandemic the use of technologies to reduce microbial contamination might have been rejected due to their cost and the lack of belief in the evidence that these technologies are worth the expenditure . The COVID-19 pandemic has shown the need to invest in infection prevention and the value of employing a range of strategies to reduce risk of transmission .”
20 • www . healthcarehygienemagazine . com • may 2024