Hand Washing: Time Well Spent

Reston Hospital Center has boosted its hand-hygiene compliance, which has led to a drop in the infection rate.

By Manoj Jain
Special to The Washington Post
Tuesday, August 5, 2008

One morning on hospital rounds, I saw a physician colleague enter the intensive care unit where a patient lay intubated and sedated. With his hands unwashed and ungloved, the physician palpated the patient's abdomen, scratched his own head and then placed his stethoscope on the patient's chest to listen to his heart. Then he walked to the nurses station, rubbed his nose and entered a note in the patient's chart.

There was nothing unusual about this. Not washing hands scrupulously remains common practice for professionals at most hospitals, even though abundant research shows that it controls outbreaks of infectious disease, reduces transmission of resistant organisms and cuts infection rates among hospitalized patients.

That same day in a public restroom, I noticed a man go straight from the urinal to the door, bypassing the sinks. Unfortunately, that's a common occurrence, too.

Despite recommendations, nearly 60 percent of health-care workers do not wash hands while on duty. Among the general public, according to a Harris Interactive survey conducted last year, 12 percent of women and 34 percent of men do not wash their hands after using a public restroom. Why?

For one thing, rigorous hand washing is time-consuming. Guidelines advise that we first rinse, then soap for 20 seconds, then rinse again for 30 seconds; after this, we paper-dry our hands and turn the faucet off using the paper towel. For health-care workers, the procedure is supposed to be followed before and after every patient encounter. That means two minutes per patient visit, which adds up to an hour for a doctor who sees an average 30 patients a day, and 2 1/2 hours per shift for an ICU nurse. I have yet to find a doctor or a nurse who is so diligent.

In the past few years, the hand-washing exercise has gotten simpler, with the increased acceptance of alcohol-based gels. I enter a patient's room, squirt gel onto my palms from the wall dispenser, then rub the back of my hands, my fingertips and my thumbs as I introduce myself and ask the patient why he or she is there. Then as I exit, I gel my hands again as I ask, "Do you have any questions?"

Despite the ease of using alcohol gel, studies show that nearly a quarter of health-care workers do not regularly disinfect their hands. Few realize that our bodies are like petri dishes teeming with 300 trillion organisms and that our hands are like swabs for the transmission of antibiotic-resistant bacteria such as MRSA, pseudomonas and C. difficile.

What can we do to improve hand-washing rates?

First, we must admit that the "Just do it!" approach of the past 150 years has failed. Behavioral theory tells us that changing behavior in a change-resistant culture cannot be accomplished with a single intervention.

We need a carrot-and-stick approach. Let the carrot be a campaign of incentives and awards for hand washers, similar to the eat-more-vegetables campaigns that many parents conduct with their children.

Then we need the stick. Health facilities need to monitor the hand-washing rate for each unit and provide feedback and improvement strategies to health workers at the bedside. Observers need to be stationed in ICUs and hospital wards, much like traffic cops at the bottom of a hill. Repeated failures to comply, as in the case of my physician colleague, would result in a letter to the offender and a note in his credentialing file or employment record.

Hospital administrators, not just their staffs, also need a stick over their heads. Starting in October, hospitals will be penalized for the consequences of unwashed hands: Medicare will no longer pay for complications arising from certain hospital-acquired infections, which in many cases result from poor hand hygiene. This will be a powerful incentive for health executives to improve hand-washing compliance.

An aggressive approach to hand washing has worked. At the University of Geneva, a hospital-wide program promoting hand hygiene helped lower the hospital-acquired infection rate from 17 percent to 10 percent between 1994 and 1998.

At Novant Health hospitals in Charlotte and Winston-Salem, N.C., a 2005 hand-washing campaign -- complete with billboards and computer screen savers -- brought about a sustained drop in MRSA and hospital-acquired infections. At Reston Hospital Center, an awareness campaign introduced in 2006 has boosted hand-hygiene compliance to more than 90 percent; it also led to a drop in the hospital's infection rate.

A 2007 study from John Hopkins showed that using simple checklists as reminders about basic hygiene such as hand washing and about proper draping, gloving and masking reduced the central intravenous line infection rate by 66 percent in ICUs.

About my physician colleague: I approached him and gently reminded him. "The patient likely has resistant bacteria -- it is really important that we wash our hands after every encounter." Suddenly self-conscious, he groped for the alcohol gel dispenser just a few feet away.

As for the man in the public restroom: I'm sure that I got his germs on my hands from the door handle.

Manoj Jain is an infectious disease physician in Memphis and a medical director of Medicare's quality improvement organization in Tennessee. Comments:health@washpost.com.

10 Germy Surfaces You Touch Every Day

Experts Tell Where Cold and Flu Viruses and Other Germs Lurk
ABC News Medical Unit
Sept. 5, 2008

Many surfaces and objects you come in contact with every day are covered in germs -- but then again, so are you. Many of the surfaces that we come into contact with on a daily basis are a breeding ground for dangerous germs -- including the viruses that can lead to cold and flu.

"Ninety percent of you is composed of germ cells," said Philip Tierno, director of clinical microbiology and immunology at NYU and author of "The Secret Life of Germs." He explained that while we are constantly in contact with germs, only a small minority will cause any harm. "Of the 60,000 types of germs that people come in contact with on a daily basis ... only about 1 [percent] to 2 percent are potentially dangerous to normal people with normal immunity," he said.

That works out well for us, because pretty much any surface contains some of these microscopic organisms. "There's very few surfaces that are truly clean," said Dr. Aaron Glatt, president and CEO of New Island Hospital in Bethpage, N.Y., and a spokesman for the Infectious Disease Society of America. "You're almost never going to culture something and not find some germs on it."

With that in mind, there is a simple activity that anyone can engage in to stay as safe as possible from surface germs.

"People should know that washing their hands is the single most important mechanism we have to prevent infection," said Glatt. While he stressed that "the optimal goal is to practice good personal hygiene, good household hygiene and good food hygiene," Tierno also noted the importance of clean hands. "You don't need to live in a bubble ... but you do need to be aware," he said. "You can touch surfaces, but just clean up before you eat or drink or before you touch your face." "If you wash your hands prior to touching your face or prior to eating or drinking, which should be the norm, you cut your risk to virtually nil."

Purses and Wallets:
Although they serve similar functions for women and men, purses and wallets are germy for entirely different reasons.
"It behooves you not to put your purse on the floor or outside ground if you can help it," said Tierno. But many women don't follow that bit of advice, so their purses pick up the bacteria from wherever they're placed -- from the soiled ground to the bathroom floor.

While some might be willing to put it there because they think the floors are cleaned regularly and thoroughly, that isn't always the case. "The way these places are cleaned is not ideal all the time," said Tierno. Instead, he recommends putting your purse on a bench or a seat.

Wallets, meanwhile, pick up a lot of bacteria from what goes into them."Men's wallets were pretty bad on the inside," said Charles Gerba, a professor of microbiology at the University of Arizona whose work has earned him the nickname "Dr. Germ."

Paper currency has a way of getting around, from germ-filled hand to germ-filled hand. It picks up germs, viruses and often trace amounts of illegal drugs -- that's not just an urban legend; several studies have confirmed that a majority of U.S. currency contains trace amounts of cocaine. And of course, all of that ends up in your wallet.

Because men keep wallets in their pockets, the wallet is close to body temperature -- an ideal temperature for bacteria to breed. "When handling the contents of your wallet, after it, wash your hands," said Tierno.

The problem isn't as bad with coins, largely because the metals -- particularly nickel -- often kill many of the bacteria.

Remote Control:
The next time you sit down for a late-night movie at home, you may want to keep your hand out of the popcorn bowl if you've been handling the remote. People are constantly handling their remote controls -- and, as Gerba points out, nobody ever disinfects them.

No wonder, then, that it is often the dirtiest object in a hotel room. Tierno recommends wiping it down at least once a week, and more often if someone who is sick handles it. Gerba points out that sickness will make the remote even worse, because people who have a cold or the flu tend to "jump in bed with the remote control and contaminate it."

The laundromat is hardly a bower of cleanliness, but even laundry done at home is rife with germs. There is about 0.1 gram of fecal material in a piece of underwear, Gerba said. That amounts to approximately 100 million E. coli bacteria in an average undergarment load.

Unfortunately, only 5 percent of people use very hot water to wash their clothes and then dry them for a full 45 minutes, a process Gerba said would kill more bacteria. Skipping these steps means that transferring wet clothing into a dryer leaves a film of germs all over your hands.

To minimize exposure to harmful bacteria, Gerba recommends doing laundry that requires bleach as a first load to disinfect the machines and saving undergarments for a final load. He also cautions against using the same sorting tables for clean and dirty laundry since the E. coli from the dirty clothes will transfer to the table and then back onto your freshly laundered clothes.

"Your clothes are a lot germier than they were 50 years ago," Gerba said. "Never kiss anyone who has just done laundry for you."

Foodwise - You may be better off preparing your food on another surface than a cutting board.

According to Gerba, there are 200 times more fecal bacteria on a cutting board than a toilet seat. The reason, he explained, is that many people rinse off their cutting board rather than thoroughly washing it. "You have potential pathogens when you're dealing with food," said Tierno. He recommended preparing a solution of a quart of water and "a jigger of bleach" and then wiping down food preparation surfaces before making anything on those areas of the kitchen.

Your Phone:
The telephone provides a convenient meeting place for two different sources of germs -- your hands and your mouth. After all, as Tierno, pointed out, "People are the source of most of the germs."These germs are not just from your hands, but sources like your saliva as well -- which is why the mouthpiece is often even dirtier than the handle.

And again, it's not a device people clean too often, which is why both land lines and mobile phones present a problem. A study done in Israel last year showed that 20 percent of hospital workers' cell phones had some form of harmful bacteria on them.

These innocuous-looking offenders are difficult to avoid, which is part of the reason why push buttons can be crawling with germs. Further, ubiquitous buttons, found on ATMs, elevators, telephones and drink machines, among other things, are located in areas that are not often cleaned and disinfected to kill bacteria and viruses.

Gerba noted that the first-floor buttons in elevators were the dirtiest."Everyone needs to go to the first floor," he said. Worse, these germs get transferred to the body part that comes in contact with faces the most -- fingers and hands. While avoiding these types of buttons can be almost impossible, Gerba does have a few recommendations. "Knuckle it or wait for someone else to push it for you."

Airplane Bathrooms:
"These are probably the worst," Gerba said. "They are the germiest restrooms you'll run across." But bathrooms in general are not as germ-ridden as other areas -- a kitchen sink or laundry machine, for example. Compared to several items on this list, toilets are a beacon of cleanliness because they are cleaned and disinfected on a regular basis, even public toilets.

Airplane bathrooms get cleaned, but the high volume of people they must cater to in a short amount of time leaves them very dirty very quickly.Gerba said a normal aircraft has one bathroom per 50 people. Discount airlines have one bathroom per 75 people.

"There is a thin layer of E. coli over the sink," and other surfaces, Gerba said, adding that many people, especially men, will not wash their hands effectively because the sink is small, and dirty hands transfer germs to the face easily. Interestingly, the cleanest toilets are probably those in public areas of a hospital, Gerba said.

Shopping Carts:
An individual probably has a fairly short interaction with the shopping cart at the local grocery store. Unfortunately, that interaction covers all the danger zones for contamination: hands, faces and food. In one study done by his group, Gerba said he found E. coli on almost half the shopping carts the group tested. These are the microbes and pathogens that are transferred from the cart to your hands, to the food you select and then to the face if the hands touch it.

In addition, children often sit in the seat provided in larger shopping carts, adding to the germ load on the cart. "That's putting a kid's butt where you put your broccoli," Gerba said. A shopping cart is a good example of an item where a quick wipe down with a disinfecting wipe and some alcoholic hand sanitizing gel recommended by the Centers for Disease Control and Prevention can prevent a lot of cross-contamination.

Prevention in a Pump

Sanitizers Give the Upper Hand Against Colds - by Dr. Clifford Bassett

From kindergarten through middle and high school, many schools and classrooms now have an abundant supply of donated liquid hand sanitizers.

These antiseptic gels are quickly becoming an additional level of protection between students and ubiquitous viruses, which, especially during the wintertime cold and flu season, are present on a variety of common surfaces.

Even the kids seem to notice a difference.

"Since we starting using liquid hand sanitizer in our school, my classmates seem to be healthier, with fewer kids getting colds," said Dylan, a seventh grader at East Side Middle School in New York City.

And in many ways, these sanitizers offer a low-cost, low-tech solution to a common, potentially costly seasonal problem.

Hand sanitizers are gaining popularity, as they are portable, easy to use and perfect for places where there is no faucet and sink available for hand washing, such as in the subway or on a train.

Thus far, several studies over the past few years have suggested that hand sanitizers do limit the spread of germs. In a September 2005 study in the journal Pediatrics, researchers showed that families who used alcohol-based gels had a 59 percent lower rate of gastrointestinal illnesses -- which cause diarrhea and vomiting -- caused by germs spread from one family member to another.

Other research has focused more on the germs that cause common colds and the flu, tracking rates of school absenteeism among kids whose families use the products.

As for my New York City based allergy practice, I have personally observed that among my employees and co-workers who aggressively use gel-based alcohol sanitizers, there has been a change in successfully avoiding the vicious cycle of recurrent cold-like infections. The goal is to reduce transmission of a variety of viruses, including the common cold as well as gastrointestinal infections.

The Centers for Disease Control and Prevention have recommended alcohol-based liquid gels over using soap and water, as long as your hands are not very soiled.

Not All Hand Sanitizers Created Equal -
One caveat: It is important to check the bottle for the level of alcohol in a sanitizer.

It is generally thought that it should contain at least 60 percent alcohol -- even better if the concentration is greater than 90 percent. Apparently, less potent solutions are not very helpful in killing the viruses that cause many household infections.

Of course, plain old soap and water is just fine if it's available. But this is not always the case when it comes to our busy lives -- especially bearing in mind that we will be taking on those pesky germs at home, school and work.

Nowadays, many different approaches are used in the fight against germs. We have "foam based" disinfectants, antibacterial soaps, cleaning wipes and aerosolized disinfectants. In a more vigorous environment, especially in health care or medical settings, iodine-based and other chemical disinfectants are frequently utilized for more robust infection-busting capability.

So now for the final question: Can hand sanitizers save you completely from cold and flu? The answer, most likely, is no. But just like conscientious hand washing, avoiding sick co-workers and maintaining a healthy diet may certainly help keep you well this holiday season.

Dr. Clifford Bassett is vice chair of the Public Education Committee for the American Academy of Allergy, Asthma and Immunology. He is also an assistant clinical professor of medicine and otolaryngology at the Long Island College Hospital in Brooklyn, N.Y.