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. 1999 Aug 21;319(7208):518.

Hand washing

Why I don’t wash my hands between each patient contact

Andrew Weeks 1
PMCID: PMC1116399  PMID: 10454415

Editor—The editorial on hand washing calls for all hospital staff to start regularly washing their hands between each patient contact.1 If, as the authors claim, there is such compelling evidence for the need to wash hands between each patient contact then why do I and the vast majority of my colleagues not do it?

Firstly, I have never seen any convincing evidence that hand washing between each patient contact reduces infection rates. The Handwashing Liaison Group assumes that we all know that hand washing is beneficial and therefore fails to put forward any evidence for it. It seems self evident that hand washing should be beneficial before and after a person has performed any procedures, examined wounds, or dealt with specifically high risk patients, but I have never seen any evidence for it in other situations. I shake hands with patients when I see them in hospital. Should I not do this, or should I wash my hands before and after each contact? Should patients be discouraged from social contacts with each other? Where is the evidence?

Secondly, I have maybe 60 “touch” contacts with patients each day, and many more with relatives. Washing hands between each contact (at 1-2 minutes per wash) would take on average 1-2 hours. Where will this time come from, and who will fund it?

If hand washing is to be performed between every patient contact then it would have major resource implications. For this it needs to be shown to be effective and worth the 15% extra staffing that would be needed to cover the extra time.

References

BMJ. 1999 Aug 21;319(7208):518.

Healthcare workers washed their hands on only a third of occasions

Rachel Sen 1, Maeve Keaney 1, Ann Trail 1, Carol Howard 1, Paul Chadwick 1

Editor—We agree with the Handwashing Liaison Group that an explicit standard for hand washing needs to be set and that hand washing should be regarded as part of the normal duty of care.1-1 The group states that “it has even been suggested that patients should be encouraged to ask carers to wash their hands.” We carried out a handwashing study on a busy general surgical ward in which patients were specifically requested to do this.

After studying an information sheet and giving written consent each patient was given a yellow card; they were asked to show this to healthcare workers if they had not seen them wash their hands before approaching them. The card read: “Please wash or disinfect your hands before and after contact with me or my environment.” The ward was visited regularly and the frequency of hand washing and disinfection observed. Over six weeks the infection control team spent roughly 16 hours on the ward. Altogether 160 staff-patient interactions were observed, giving 320 opportunities for hand washing before and after the interaction. The overall frequency of hand washing by all healthcare workers was 37% (118 occasions).

Patients were reluctant to show the cards to healthcare workers, and we had to pin them above the bed head to remind staff about the need for hand washing and disinfection. Some patients were quite “macho” when discussing using the card among themselves but nevertheless did not show it to the relevant members of the healthcare team. During the observation period the infection control team did not observe the yellow card being shown on a single occasion, although many occasions when it would have been appropriate occurred. Staff on the ward reported that they had not been shown the card.

By contrast, a study by McGuckin in hospitals in New Jersey found that 57% of patients on medical and surgical wards had asked their healthcare workers “Did you wash your hands?” at least once during their inpatient stay, and 68% of these said that they felt comfortable doing so. These patients had been told that “your healthcare workers will expect you to ask them about handwashing” and had been given supportive literature on the importance of hand washing.1-2

Further work is needed to find out the best way to empower patients in the United Kingdom to ask the question “Have your washed your hands?” Meanwhile we will have to rely on self motivated staff to improve compliance with hand washing.

References

  • 1-1.Handwashing Liaison Group. Hand washing. BMJ. 1999;318:686. doi: 10.1136/bmj.318.7185.686. . (13 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Boodman SG. Medicine’s dirty little secret. Washington Post 1997 Sept 30.
BMJ. 1999 Aug 21;319(7208):518.

Handwashing facilities are inadequate

S Kesavan 1

Editor—The editorial by the Handwashing Liaison Group does not fully address staff’s reasons for not washing hands.2-1 In a study of nursing staff, lack of proper handwashing facilities and possible damage to the skin caused by hand cleansing were mentioned as reasons for not washing the hands.2-2

Colleagues and I studied the adequacy of handwashing facilities at 264 sinks on 19 elderly care wards in seven hospitals in the United Kingdom and found many deficiencies.2-3 Twenty nine sinks were simply inaccessible, often being blocked by ward equipment such as hoists or trolleys, or were placed badly (for example, behind beds, curtains, or doors). Cleansing agents were absent from 32 ward sinks. Antiseptic agents such as chlorhexidine were absent from 246 ward sinks. Fifteen of 19 sinks in treatment room also did not have an antiseptic agent. Only six sinks had hand cream.

I recommend the implementation of a standard checklist for hospital handwashing facilities.

References

  • 2-1.Handwashing Liaison Group. Hand washing. BMJ. 1999;318:686. doi: 10.1136/bmj.318.7185.686. . (13 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Heenan A. Hand washing practices. Nursing Times. 1992;88:69–70. [PubMed] [Google Scholar]
  • 2-3.Kesavan S, Barodawala S, Mulley GP. Now wash your hands? A survey of hospital handwashing facilities. J Hosp Infect. 1998;40:291–293. doi: 10.1016/s0195-6701(98)90306-1. [DOI] [PubMed] [Google Scholar]
BMJ. 1999 Aug 21;319(7208):518.

Alcohol hand rubs are better than soap and water

C Richard B Welbourn 1,3-2001, Steve M Jones 1

Editor—The editorial on hand washing by the Handwashing Liaison Group advocates a culture change in hand decontamination, with management and consultants showing a greater commitment and setting an example to trainees.3-1

Alcohol hand rubs are a rapid, effective alternative to soap and water washes.3-2,3-3 We use alcohol gel dispensers on acute surgical wards and prefer them. One press dispenses enough gel to cover the hands. It’s quick and easy, doesn’t dry skin, and is not as messy as soap and water.

The key is to have alcohol gel dispensers readily available: on three Nightingale acute surgical wards we have installed 25 dispensers for 72 patients. Every bed therefore has one within easy reach. If these were more commonly available they would be used and repeated exhortations to wash hands with soap and water would be unnecessary.3-4

References

  • 3-1.Handwashing Liaison Group. Hand washing. BMJ. 1999;318:686. doi: 10.1136/bmj.318.7185.686. . (13 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Hoffman PN, Wilson J. Hands, hygiene and hospitals. PHLS Microbiol Digest 1994;11(4).
  • 3-3.Ayliffe GA, Babb JR, Davies JG, Lilly HA. Hand disinfection: a comparison of various agents in laboratory and ward studies. J Hosp Infect. 1988;11:226–243. doi: 10.1016/0195-6701(88)90101-6. [DOI] [PubMed] [Google Scholar]
  • 3-4.Daniels IR, Rees BI. Handwashing: simple, but effective. Ann R Coll Surg Engl. 1999;81:117–118. [PMC free article] [PubMed] [Google Scholar]
BMJ. 1999 Aug 21;319(7208):518.

Hand washing is more common among healthcare workers than the public

Paul M Hateley 1,2, P A Jurnaa 1,2

Editor—The Handwashing Liaison Group has written about the need for healthcare staff to wash their hands.4-1 To increase rates of hand washing in a healthcare setting is a challenge to everyone concerned with implementing infection control procedures. Poor hand hygiene in hospitals and lack of understanding of its importance in preventing infection and the spread of antibiotic resistance may reflect poor practice and attitudes in the community.

Frustrated by our attempts to improve compliance with hand washing and to make staff appreciate its importance, we performed an observational study of the handwashing behaviour of 200 healthcare staff in a personal setting. Members of the infection control team unobtrusively observed 100 female and 100 male healthcare workers (predominantly nurses, doctors, caterers, and nursing and medical students) using the toilets in the medical education centre; they counted the number who washed their hands after using the toilets. To compare their handwashing rates with those of members of the public, the same study was performed in public toilets in a railway station. We found that 59 of the male healthcare workers and 83 of the female healthcare workers washed their hands after using the toilet, compared with 34 of 100 male members of the public and 56 of 100 female members of the public.

The apparent difference in handwashing rates between men and women may account for the differences in handwashing behaviour that some observers have reported for nurses and doctors, among whom one or other sex predominates.4-2 If these results are representative of our community as a whole then improving handwashing rates on the wards will continue to challenge us.

Everyone needs to appreciate the importance of washing their hands. In addition to the recommendations made by the Hand Washing Liaison Group, we recommend that basic hygiene should be taught in schools as part of the curriculum; public health information campaigns in the media should direct the public’s attention to the potentially lifesaving practice of washing one’s hands.

References

  • 4-1.Handwashing Liaison Group. Hand washing. BMJ. 1999;318:686. doi: 10.1136/bmj.318.7185.686. . (13 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4-2.Dorsey ST, Cydulka RK, Emerman CL. Is hand washing teachable? Failure to improve hand washing behaviour in an urban emergency department. Acad Emerg Med. 1996;3:360–365. doi: 10.1111/j.1553-2712.1996.tb03451.x. [DOI] [PubMed] [Google Scholar]
BMJ. 1999 Aug 21;319(7208):518.

Dermatitis associated with frequent hand washing should have been mentioned

Robert MacDermott 1

Editor—I do not disagree with anything in the editorial about hand washing, but it should have acknowledged the problem of dermatitis associated with frequent hand washing.5-1,5-2 This condition causes considerable discomfort to a large proportion of healthcare workers, most of whom suffer in silence. A definition of what constitutes a patient contact requiring hand washing would have been helpful. I regularly have contact with over 50 patients in a day and dread to think how red, dry, and cracked my hands would be if I washed after every contact. In a recent survey of intensive care staff the prevalence of occupational hand dermatitis was 55.6%, rising to 69.7% in those washing more than 35 times per shift.5-3

No mention was made in the editorial of the appropriate solutions with which to wash. Certain solutions are kind to hands, while others are notorious for producing dermatitis.5-2 The newly introduced handwashing solution in wards in my hospital is harsh to hands, and anecdotal reports suggest that nurses may be avoiding washing their hands because of this. The free provision of hand moisturisers could be of value in preventing dermatitis.

The role of gloves in preventing cross infection was surely worth a mention. For those staff not allergic to glove components this may be more acceptable than frequent hand washing.

Many patient contacts are not essential (for example, a handshake, routine daily inspection of wounds). Advice on the avoidance of non-essential patient contacts would have been useful.

This was a missed opportunity to give practical advice that might increase compliance with hand washing. Each member of the Handwashing Liaison Group should state how many patient contacts requiring hand washing he or she has each day.

References

  • 5-1.Handwashing Liaison Group. Hand washing. BMJ. 1999;318:686. doi: 10.1136/bmj.318.7185.686. . (13 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5-2.Mathias CGT. Contact dermatitis: when cleaner is not better. Occup Health Safety. 1984;53:45–50. [PubMed] [Google Scholar]
  • 5-3.Forrester BG, Roth VS. Hand dermatitis in intensive care units. J Occup Environ Med. 1998;40:881–885. doi: 10.1097/00043764-199810000-00008. [DOI] [PubMed] [Google Scholar]
BMJ. 1999 Aug 21;319(7208):518.

Stethoscopes and white coats are sources of nosocomial infection

D Varghese 1,2, H Patel 1,2

Editor—The Handwashing Liaison Group recommends that hands should be decontaminated before patient contact.6-1 Two other sources of infection are often overlooked.

The white coat has long been a symbol of the medical professional, and about half of patients still prefer their doctor to wear one.6-2 This might not be the case if they realised that white coats harbour potential pathogens and are thereby a source of cross infection, especially in surgical areas.6-3 White coats are often left during rest periods in places that are not clean; in addition, some doctors use their white coats as overcoats, which increases potential risks. Even though it has been recommended that white coats are removed and a plastic apron put on before examining wounds,6-3 this rarely happens, particularly during surgical ward rounds. Many trusts now insist that junior doctors in particular wear a white coat as part of a mandatory dress code; this ruling needs to be reviewed.

Another source of potential pathogens is the diaphragm piece of the stethoscope. Auscultation of the abdomen is an essential part of examining surgical patients, and on a typical ward round regular use is made of the house surgeon’s stethoscope. In a recent study 11 genuses and species of bacteria were isolated from the stethoscope diaphragm, the main pathogens being coagulase negative staphylococcus and Staphylococcus aureus.6-4 The risk of cross infection could be greatly reduced by simply cleaning the diaphragm with an alcoholic wipe between examining patients.

References

  • 6-1.Handwashing Liaison Group. Hand washing. BMJ. 1999;318:686. doi: 10.1136/bmj.318.7185.686. . (13 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6-2.Menahem S, Shvartzman P. Is our appearance important to patients? Fam Pract. 1998;15:391–397. doi: 10.1093/fampra/15.5.391. [DOI] [PubMed] [Google Scholar]
  • 6-3.Wong D, Nye K, Hollis P. Microbial flora on doctors’ white coats. BMJ. 1991;303:1602–1604. doi: 10.1136/bmj.303.6817.1602. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6-4.Marinella MA, Pierson C, Chenoweth C. The stethoscope. A potential source of nosocomial infection? Arch Intern Med. 1997;157:786–790. doi: 10.1001/archinte.157.7.786. [DOI] [PubMed] [Google Scholar]
BMJ. 1999 Aug 21;319(7208):518.

Muslim teaching gives rules for when hands must be washed

A Majid Katme 1

Editor—As a practising Muslim doctor I was interested in the editorial on hand washing.7-1 I thought it would be useful for doctors to know our Islamic teachings in connection with hand washing, and especially to remind the many thousands of Muslim doctors who work in our clinics and hospitals today.

The last Prophet Muhammad ordered us to wash our hands many times and in connection with these occasions:

  • on waking from sleep;

  • when coming out of the toilet;

  • before and after eating any food;

  • after touching our genital or anal area or that of others (as in a doctor’s examination);

  • after touching a dead body;

  • after touching any dirty or suspicious thing;

  • when a dog is touched, to wash our hands seven times (one of them in the sand);

  • in ablution before the five daily prayers, when the hands are washed three times on every occasion (plus washing the face, throat, nose, ears, arms, and feet and rubbing the hairs with water).

These frequent hand washings are done by every practising Muslim, whatever his or her job. They are more than enough for the hygiene and protection of every one of us, especially doctors.

I appeal to Muslim doctors to adhere to Islamic teachings, at least to prevent infections from patients, especially after examination.

References

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