INFECTION CONTROL

PACUWhy Hand Washing Is Vital!

William Clayton Petty, MD, Guest Columnist
Hand washing is one of the oldest methods of reducing infections. Recent evidence based research has re-conrmed the efcacy of proper hand hygiene and recommendations for hand hygiene by the CDC and WHO are outlined. The PACU is a unique environment; patients are in a crossroad of infection; many patients are exposed to infections coming from various wards brought to the PACU through the OR. The PACU nurse is not only responsible for observing and monitoring the patients vital signs but is also responsible for making sure patients are not exposed to an additional risk, e.g. a hand-transmitted infection. Keywords: hand washing, hand hygeine, preventing infections, MRSA, improving hand-hygeine compliance. 2009 by American Society of PeriAnesthesia Nurses

IF YOU WERE pregnant, poor, carrying an illegitimate baby, or were having birth complications in Vienna in 1845 or before, you went to the Vienna General Hospital. Before 1846 you had a good chance of dying while in the hospital and most women stayed at home to deliver. You could improve your chance of living by being admitted to the Second Obstetrical Clinic operated by midwives, where the mortality rate was only 2.03%. If you went to the First Obstetrical Clinic, staffed by medical students and obstetricians, you raised your risk of dying to 13.10%. But if you went to the First Obstetrical Clinic in June 1847, your risk of dying had been reduced to 2.38%.1,2 What made the big difference? In 1846, Dr Ignaz Semmelweiss best friend cut himself with a scalpel while performing an autopsy; he died and his autopsy showed signs similar to mothers who died of puerperal fever or childbirth fever (a bacterial infection of the female genital tract after childbirth) after delivery. After a thorough investigation, Dr Semmelweis found that medical students and obstetricians were going directly from the autopsy room to the First Obstetrical Clinic and examining women vaginally without properly wash-

ing their hands. He ordered the medical students, with some resistance at rst, to wash their hands with chlorinated lime before examining patients. The result was a reduction in the maternal death rate from 13.10% to 1% in 2 years; in the rst month, the mortality rate fell to 2.38%. When Dr Semmelweis moved to another hospital and had full authority over the maternity suites, he was able to reduce the mortality rate to 0.82%, a miracle considering germ theory had not yet been discovered.1,2 Today Dr Semmelweis is considered by some to be the Defender of Motherhood for his heroic contribution to medicine. Why then is it that we have to be continually reminded of the simple practice of hand washing to reduce infections? Is it complacency, thinking that antibiotics can cure any infection? If this is true, why is methicillin-resistant Staphylococcus aureus (MRSA) so prevalent and killing so many? Health care workers have been found to have 3.9 3 104 to 4.6 3 106 aerobic bacteria colony-forming units on their hands. Despite this known fact of contamination, the average duration of hand washing by health care workers declined from 24 seconds in 1989 to 4.75.3 seconds in 1997.3 Hand washing for health care workers should be a reex and not a chore. Yet, many health care workers in areas where infection is easily transmitted from one patient to another on contaminated hands, eg, in the PACU, do not wash their hands repeatedly during the day. Many excuses such as hand washing is low on my priority list because I am busy taking care of patients; since I wear gloves for dirty jobs in the PACU, I do not need to wash
Journal of PeriAnesthesia Nursing, Vol 24, No 4 (August), 2009: pp 250-253

William Clayton Petty is a Former Professor of Anesthesiology, Department of Anesthesiology, University of Utah, Salt Lake City, UT. The author reports no conict of interest. Address correspondence to Dr Clayton Petty, P.O. Box 716, Cedar City, UT 84721; e-mail address: williamcpetty@yahoo.com. 2009 by American Society of PeriAnesthesia Nurses 1089-9472/09/2404-0009$36.00/0 doi:10.1016/j.jopan.2009.05.101
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my hands; it is too inconvenient for me to wash my hands; I forget; I dont have time; there is no place for me to wash my hands; or hand washing makes my skin dry and irritated. These are poor excuses for any nurse, nursing tech, or physician working in the PACU! Recently there have been two articles substantiating the effect of hand washing on reducing in-hospital infections. The rst was an effort to improve compliance in hand washing in nine hospitals and seven partnerships of the Novant Health system in North and South Carolina.4 The second was an effort to improve hand hygiene with the use of a belt-attached alcohol dispenser worn by anesthesia providers in the OR.5 In one of the facilities of Novant Health in 2004, there was a death of a child from an outbreak of MRSA. The pursuant investigation found, among other things, that health care workers were noncompliant to inplace standards for hand hygiene put forth by the Centers for Disease Control and Prevention (CD).4 Because hand hygiene has been proven repeatedly to be highly effective in reducing morbidity and mortality, the best and simplest approach was to institute a comprehensive system-wide program stressing hand hygiene, supported by education, marketing, clinical improvement, and clinical care departments. Hand hygiene compliance was adopted as a 3 year corporate goal, thus giving needed support from administration to the program.4 Novant Health established a Hand Hygiene Committee composed of key clinical and administrative leaders from all units and was made responsible for collecting, analyzing, and disseminating the data reports to the organization to reach a corporate goal of 90% compliance.4 After reviewing CDC recommendations for hand hygiene practices already in place, Novant Health instituted a corporate-wide awareness campaign of (1) traditional nursing and physician memos and poster board communications; (2) hard-hitting posters that implied the staff could harm a patient by poor compliance, eg, You could kill him with your bare hands, and What you cant see is killing them; (3) hand hygiene fairs; (4) a Gel in, Gel out button; (5) visitor education programs; and (6) an internal marketing campaign, with life-sized cartoon cut-outs, emphasizing hand hygiene at visitor centers and lobbies. All components were designed to make hand hygiene an automatic compliance, like fastening your seat belt, for all health care workers. A culture was created where noncompliance was unacceptable and where patient safety became an individual employee responsibility. Hand hygiene compliance in Novent Health facilities was greater than 90% after November 2006 and has been maintained at this level since the introduction of the campaign. The MRSA hospital-acquired infection rate was decreased from 0.52 to 0.24 per 1000 patient days, representing a 54% reduction associated with improved compliance. The reduction in MRSA infections meant

there were an estimated 105 fewer MRSA hospitalacquired infections in the Novant Health system, eg, 234 infected patients in 2005 reduced to 129 patients at years end in 2008.4 The intense campaign was successful in reducing MRSA infections and changing the behavior of health care workers. Novant Health has made available, at no cost to health care organizations, all posters, stickers, ads, banners, and other marketing treatments on their website (http://www.washinghandssaveslives.org). As of April 2009, 859 US organizations and 41 foreign organizations have accessed the materials.4 A clinical research group at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire recently reported a reduction in the rate of contamination of peripheral intravenous (IV) stopcocks by anesthesia providers in the OR from 17.2% to 3.8% by the use of an alcoholdispenser worn by anesthesia providers.5 Each time the Sprixx GJ Personal Dispenser (Harbor Medical, Inc, Rye Beach, NH) is pressed it expresses 0.75 mL of a uid gel alcohol-based hand cleaner.6 The study data for the clinical research was obtained over a 2 month period and involved 111 patients (58 control, 53 treatment). The 46 anesthesia providers in the control group used standard hand hygiene methods in place, ie, a wall-mounted alcohol-based gel dispenser located only three steps from the OR anesthesia workstation and a 70% ethanol liquid dispenser on the anesthesia cart. The 97 anesthesia providers in the treatment group used the same hand hygiene methods in place but also wore a Sprixx GP Personal Dispenser. The outcome data of the effectiveness of wearing a dispenser for hand hygiene was derived by measuring the extent of contamination of peripheral IV stopcocks and analysis of hospital-associated infections measured in the 30-day period after surgery. The results are summarized in Table 1.5 Ten of 58 (17%) patients in the control group developed hospital-acquired infections that included ventilatorassociated pneumonia, wound infection, bloodstream infection, and urinary tract infection. The authors of the anesthesia research study concluded that a simple cost-effective device containing an Table 1. Contamination and Infections
Control Group n 5 58 Stopcock positive Nosocomial infection Death 32.8% 17.2% 3.4% Sprixx GP Personal Dispenser Group n 5 53 7.5% 3.8% 0

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for the PACU have been combined here for the sake of brevity:
d

Figure 1. Sprixx GJ Personal Dispenser. Reprinted with permission by Sprixx. This gure is available in color online at www.jopan.org.

alcohol-based solution signicantly reduces intraoperative transmission of potentially pathogenic bacterial organisms. Would hospital-acquired infections have been further reduced if nurses in the PACU, ICU, and wards had used a personal dispenser device? In May 2009, the World Health Organization (WHO) released the extensive 270-page WHO Guidelines on Hand Hygiene in Health Care.7 The report is a sentinel effort of the WHO and is a logical outgrowth of the theme Save Lives: Clean Your Hands of the First Global Patient Safety Challenge. More than 117 countries have pledged support for WHO hand hygiene efforts. The WHO guidelines are more extensive than those found in the CDCs 45-page document Guideline for Hand Hygiene in Health-Care Settings3 published in 2002. Both sets of guidelines use a similar grading system, have a similar layout and discussion of issues, and review evidence extensively. The CDC guidelines are intended primarily for the United States and the WHO guidelines were conceived in a more global perspective. The My Five Moments for Hand Hygiene program included in the WHO guidelines document deserves emphasis because of its success rate in 400 hospitals worldwide in 2006 to 2008. The evidence-based program is easy to follow and reminds the health care worker to practice good hand hygiene: 1. before touching a patient 2. before a clean/aseptic procedure 3. after body uid exposure risk 4. after touching a patient 5. after touching patient surroundings All ve steps are strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies and a strong theoretical rationale. Because the CDC and WHO hand hygiene recommendations are very similar, some of them especially applicable

Indications for hand washing and hand antisepsis: B When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body uids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water. - Proper hand washing technique is essential for best results: d Wet hands with water d Apply enough soap to cover all surfaces d Rub hands palm to palm d Right palm over left dorsum with interlaced nger and vice versa d Palm to palm with ngers interlaced d Backs of ngers to opposing palms with ngers interlocked d Rotational rubbing of left thumb clasped in right palm and vice versa d Rotational rubbing, backwards and forwards with clasped ngers of right hand in left palm and vice versa d Rinse hands with water d Dry thoroughly with a single-use towel d Use towel to turn off faucet/tap d Duration of entire procedure: 40 to 60 sec and your hands are safe. - Paper towels, warm air dryers, and cloth towels were no different in the efciency to dry wet hands. - When using towels, pat dry instead of rubbing dry to avoid cracking. B If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands or wash hands with an antimicrobial soap and water. - Proper hand rubbing with alcohol-based hand rub is: d Apply a palm full of the product in a cupped hand and cover all surfaces d Rub hands palm to palm d Right palm over left dorsum with interlaced nger and vice versa d Palm to palm with ngers interlaced d Backs of ngers to opposing palms with ngers interlocked d Rotational rubbing of left thumb clasped in right palm and vice versa d Rotational rubbing, backwards and forwards with clasped ngers of right hand in left palm and vice versa d Duration of the entire procedure: 20 to 30 sec and, once dry, your hands are safe - Alcohols are rapidly germicidal and work by denaturing proteins; 60% to 70% alcohol will

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kill bacteria, mycobacteria, fungi, herpes simplex virus, HIV, inuenza virus, hepatitis B virus, and probably hepatitis C virus. B Decontaminate hands before having direct contact with patients B Decontaminate hands before donning sterile gloves B Decontaminate hands after removing gloves B Before eating and after using a restroom, wash hands with a nonantimicrobial soap or antimicrobial soap and water B Use an alcohol-based hand rub as the preferred means of routine hand antisepsis in all the above listed items B Soap and alcohol-based hand rub should not be used concomitantly Selection of hand hygiene agents: B Provide personnel with efcacious hand hygiene products that have low irritancy potential B Do not add soap to a partially empty soap dispenser; this practice of topping off dispensers can lead to bacterial contamination of soap Skin care: B Provide health care workers with hand lotions or creams to minimize the occurrence of irritant contact dermatitis General considerations: B Do not wear articial ngernails or extenders when having direct contact with patients at high risk 1 B Keep natural nail tips less than 4 -inch long B Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur B Remove gloves after caring for a patient B Potable water combined with a detergent will remove dirt and dissolve fatty materials

Proper hand washing technique is essential for best results d Irritant contact dermatitis ranges from 25% to 55% B Alcohols are less irritating than soap and water B Putting on gloves with wet hands increases skin irritation B Washing hands regularly with soap and water immediately before or after using an alcoholbased product is not only unnecessary, but may lead to dermatitis d Use of sterile gloves: B The National Institute for Occupational Safety and Health mandates the use of gloves during all patient-care activities involving exposure to blood or body uids that may be contaminated with blood B Reduces the risk of contaminating your hands - Reduces the risk of germ dissemination to the environment and of transmission to patients Proper hand hygiene by health care workers is one of the simplest, most effective means of decreasing morbidity and mortality in patients in health care settings. Hand hygiene removes dirt and organic material as well as microbial contamination acquired by contact with patients and the environment. The leading cause of health care associated infection and spread of multiresistant organisms is the failure to practice proper hand hygiene. There is a definite link between improved hand hygiene practices and reduced infection and cross-transmission rates.
B

The PACU nurse is a key link in the care of surgical patients and plays a major role in reducing or increasing cross contamination and direct contamination of patients recovering from anesthesia and surgery. Efforts should be made in every PACU to make hand hygiene an automatic compliance and give PACU personnel ownership in patient safety.

References
1. Thom R. Semmelweis: Defender of Motherhood. CDC Online, reprinted with permission from Pzer, Inc. Available at: www.cdc.gov/ ncidod/eid/vol7no2/cover.htm. Accessed April 1, 2009. 2. NNDB (Notable Names Database). Ignaz Semmelweis. Available at: www.nndb.com/people/601/000091328. Accessed April 1, 2009. 3. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Morb Mortal Wkly Rep. 2002;51:1-45. 4. Lederer JW Jr, Best D, Hendrix V. A comprehensive hand hygiene approach to reducing MRSA health care-associated infections. Jt Comm J Qual Patient Saf. 2009;35:180-184. 5. Koff MD, Loftus RW, Burchman CC, et al. Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device. Anesthesiology. 2009;110: 978-985. 6. Harbor Medical Inc. Sprixx GJ Personal Dispenser Kit. Material Safety Data Sheet. Revision date 16 May 2007. Available at: http://sprixx. com. Accessed April 1, 2009. 7. World Health Organization. Guidelines on Hand Hygiene in Health Care, May 2009. Available at: http://whqlibdoc.who.int/publications/ 2009/9789241597906_eng.pdf. Accessed June 5, 2009.