Health Care Workers' Crucial Barriers
- By Judith Green-McKenzie, M.D., MPH, FACOEM, FACP, Garson Caruso, M.D., MPH
- Apr 01, 2006
New strategies for improving hand hygiene practices aim to reduce transmission of pathogens to patients and personnel in health care settings.
HOSPITAL-acquired (nosocomial) infections are estimated to occur in nearly 10 percent of all acute care hospitalizations.1 The estimated incidence is more than 2 million cases per year, resulting in an added expenditure in excess of $4.5 billion.2 Transmission of both normal and pathological microorganisms by the hands of health care workers (HCWs) is one of the main routes of infection spread.3 Skin microorganisms may be considered resident flora or transient flora.
Resident flora, attached to the deeper layers of the skin, are persistently found on the skin and of low pathogenicity. Transient flora, colonizing the superficial layers of the skin, are consistently present on the skin, have higher pathogenicity, and are responsible for most instances of nosocomial infection transmission.4 The skin functions to reduce water loss, protect against microorganisms and abrasive action, and provide a permeability barrier to the environment.5
Although contaminated sources such as infected or draining wounds or wound dressings are of obvious concern, colonization of the hands of HCWs by transient flora from intact patient skin is also common. Normal skin sheds approximately a million cells containing viable microorganisms daily6, allowing contamination of objects in a patient's immediate environment, including gowns, bed linen, and furniture. Thus, HCWs can acquire transient organisms from apparently innocuous patient care activities.7
The role of infectious agents' transmission by the hands of HCWs was independently recognized in the mid-19th century by Semmelweis in Austria, Holmes in the United States, and Lister in Scotland.8 Since that time, hand washing with soap and water or other disinfectant agents has become a standard practice for infection control in health care settings.
Coming Clean
Hand washing with an antiseptic agent (an antimicrobial substance applied to skin to reduce the number of microbial flora) has long been considered effective in reducing the incidence of health care-associated infection. Compounds currently used for both routine and pre-surgical preparation hand antisepsis in health care settings include plain (non-antimicrobial) soap, chlorhexidine, chloroxylenol, hexachlorophene, quaternary ammonium compounds, and triclosan. Optimal hand hygiene should balance protecting the skin and resident flora, and reducing or eliminating transient flora. HCW compliance with recommended hand washing practices has been found to be low, with physicians being the least compliant.9
Lack of appreciation of the potential for pathogenic contamination during routine patient care activities appears to be one factor in non-compliance. Comfort factors, such as development of skin irritation manifested as irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD) due to repeated use of soaps, detergents, or antiseptic compounds, is another perceived barrier. HCWs' ability to tolerate available products (soap or other antimicrobial compounds) and acceptability of the product also may affect compliance.5 As frequent hand washing increases skin pH (decreases acidity), removes fatty acids (defatting), and reduces the barrier function of intact skin, reduction in normal skin antibacterial properties may result.10 Damaged skin harbors more pathogens, and washing damaged skin is less effective in reducing microorganism counts than washing intact skin. With continued patient care, microorganisms accumulate on the hands of HCWs over time.3
Compliance may depend on convenience factors, including the degree of accessibility and the hand-washing or cleansing facilities' ease of use. In addition, HCWs who perceive time pressure as a result of workload, understaffing, and patient care demands may prioritize other patient-care activities over hand hygiene. Finally, cognitive factors such as lack of knowledge of hand hygiene guidelines or of scientific information regarding effectiveness, assumption of adequate protection from glove use, or simply forgetting contribute to non-compliance.5
Denatural Selection
Alcohol-containing, waterless antiseptic agents applied to the hands are designed to reduce the number of viable microorganisms. Commonly used in Europe for many years, their use has lately become more widespread in the United States. In 1985, the Centers for Disease Control and Prevention recognized a limited role for alcohol-based hand antiseptics. Guidelines promulgated by the Association for Professionals in Infection Control (1995) expanded the role of these antiseptics, and recommendations were further expanded by CDC's Healthcare Infection Control Practices Advisory Committee (1996). More recently, CDC released a comprehensive guideline (2002) consolidating previous work recommending routine use of alcohol-based hand antiseptics in health care settings.5
This article originally appeared in the April 2006 issue of Occupational Health & Safety.