Healthcare Hygiene magazine October 2019 | Page 34

hand hygiene
By By Paul Alper
The Problem We Only Think We Solved
All truth passes through three stages.
First, it is ridiculed. Second, it is violently
opposed. Third, it is accepted as self-evident.
– Arthur Schopenhauer, philosopher
W
hat would Ignaz Semmelweis think if he were able to
observe the state of healthcare hand hygiene today?
The Austrian physician who, while working at the Vienna
General Hospital’s first obstetrical clinic, first proved the link
between hand hygiene (disinfection with a chlorinated lime
solution) and the reduction of infections (child bed fever)
in 1847, might wonder why so much, yet so little progress
has taken place in the 172 years since his discovery. In spite
of the innovations highlighted below, global hand hygiene
compliance rates remain no greater than 50 percent, and
patients are still getting infections from pathogens such
as methicillin-resistant Staphylococcus aureus (MRSA),
methicillin-susceptible Staphylococcus aureus (MSSA) and
vancomycin-resistant Enterococcus (VRE), associated with
transmission by unclean hands.
Semmelweis certainly experienced the first two stages of
truth as Schopenhauer observed them. Many contemporary
doctors were offended by the notion they should wash their
hands, and not only ridiculed him, but also shunned him.
Acceptance of the benefits of hand hygiene as “self-evi-
dent” took the work of Louis Pasteur and Joseph Lister and
occurred years after Semmelweis’s death.
Since that seminal work more than 100 years ago, there
have been three major disruptive changes in healthcare
hand hygiene.
➊ “Bag in a Box” (BIB) Soap Technology in the 1970s:
This invention introduced sealed, sanitary soap cartridge
refills with a proprietary valve that only fit compatible,
proprietary dispensers. The inner workings of the dispenser
were engineered to accept the BIB refill. Think “razor”
(the dispenser) and “disposable razor blade” (bag in a box
refill) business model. Pushing or pulling the dispensing
bar activated a valve that allowed the soap to flow from
the dispenser. This sanitary approach eliminated the use
of gallons that could fill any bulk reservoir soap dispenser
by simply pouring in the liquid.
Sani Fresh® invented the original BIB with a “pull” style
dispenser, and eventually Kimberly-Clark purchased that
company. GOJO accelerated this trend by entering into the
market with its “push” style dispenser. Of note is that the
bulk soap sold in the range of $3 to $5 per gallon, but with
BIB refills costing about $2 to $3 per 800 ml refill, the price
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of soap went up to more than $10 to $12 per gallon. Mocked
as ridiculously expensive by purchasing departments, the
Sani Fresh team pushed its sanitary benefits with clinical
decision makers, and today, sealed soap, sanitizer and lotion
refills are the standard of care in healthcare, with the use
of bulk, pour and fill style dispensers virtually non-existent.
➋ Alcohol Hand Sanitizer: “We’ll never use that stuff;
we wash with soap and water,” was the typical response
from infection preventionists in the late 1980s and 1990s
when introduced to alcohol based hand sanitizers (or hand
disinfectants and rubs, as they were also known in Europe).
The idea of no longer using soap and water was ridiculed
by infection preventionists. It was a violation of everything
they took to be self-evident when it came to soap-and-
water hand washing.
The widespread use of alcohol for hand disinfecting began
in the 1970s in Europe but did not come into serious use in
US hospitals and healthcare facilities until the late 1980s,
when PURELL® and other brands were first introduced into
institutional use. Once healthcare workers realized how much
faster and efficient it was to clean hands with an alcohol
hand sanitizer, objections went away, and institutional use
accelerated. Use of alcohol hand sanitizer further increased
with the retail launch of PURELL and the first TV ads that ran
in 1997, which led to its use becoming a societal norm and
part of the popular culture. The CDC’s updated Healthcare
Hand Hygiene Guideline in 2002 cemented alcohol-based
hand sanitizers as the absolute standard of care and the
primary way healthcare workers sanitized their hands; the
only exception to this standard is when hands are visibly
soiled or recently exposed to bodily fluids or spores, at
which point they need to be washed with soap and water.
➌ Electronic Monitoring for Hand Hygiene
Compliance: Hand hygiene compliance, whether a worker
properly performs hand hygiene when indicated, has
typically been measured by direct observers attempting
to watch healthcare workers. This practice mimics that of
“secret shoppers,” whereby the observers try to remain
unknown to the workers and attempt to discreetly record
whether they do hand hygiene when indicated. This system
is inherently flawed however, because if a secret shopper
observes the lack of hand hygiene and does not intervene,
they are enabling risk of harm to the patient.
An additional problem is that healthcare workers—no
matter how discreet the secret shopper is—know when
they are being observed and behave differently. This
phenomenon is known as the Hawthorne Effect: people
behave differently when they know they are being watched.
Further compounding the problem is that direct observation
typically only captures less than 1 percent of all hand hygiene
october 2019 • www.healthcarehygienemagazine.com