In May 1847, Ignaz Philipp Semmelweis (1818–1865) showed by experiment that handwashing could prevent infections (Noakes et al, 2008). He instigated a hand-washing regime at the maternity clinic of the Vienna General Hospital, where monthly maternal mortality rates from puerperal fever (caused by group A beta-haemolytic Streptococcus) were as high as 20%. The following month, mortality on the labour ward was 1.2%.
Despite this early evidence of the effect of handwashing on infection, as Dr Atul Gawande (2004: 1285) observed: ‘The Journal of Hospital Infection and Infection Control and Hospital Epidemiology… read like a sad litany of failed attempts to get us to change our contaminating ways.’ Data from the World Health Organization (WHO) show an apparent continuing failure of health-care workers (HCWs) to protect their patients. When the WHO (2009: 5) reviewed 77 hand-hygiene peer-reviewed articles from 1981–2008, it reported: ‘Adherence of HCWs to recommended hand hygiene procedures has been reported as variable, with mean baseline rates ranging from 5% to 89% and an overall average of 38.7%.’
Why should this sorry state of affairs exist? One possible reason might be poor availability of handwashing facilities. Flint (2005: 141) pointed to what seems to be a perennial problem: ‘So here I am in hospital wanting to help a woman change her baby's nappy… help her with breastfeeding, or even to peer at her perineum… and in order to protect her from my dirty hands I must wear gloves because half the time I can't wash my hands—no soap.’ Meanwhile, a UK study (Cloutman-Green et al, 2014) concluded ‘that the visibility of sinks directly impacts on handwashing frequency and duration and also impacts on levels of bacterial contamination on and around the sink area’.
One attempt by the WHO to emphasise that effective hand hygiene is the single most important measure to prevent and control health-care-associated infections was its introduction of the concept of ‘Five Moments for Hand Hygiene’, according to which ‘HCWs are requested to clean their hands (1) before touching a patient, (2) before clean/aseptic procedures, (3) after body fluid exposure/risk, (4) after touching a patient and (5) after touching patient surroundings’ (WHO, 2009: 26).
But note the term ‘requested’. Let's assume that handwashing facilities abound. In such circumstances, is it perhaps time to punish those HCWs whose poor hand hygiene puts patients at risk? On the other hand, when infectious disease expert and former nurse Professor Dinah Gould (2014) reflected on her experience as a patient, she noted that where HCWs' poor hand hygiene was concerned, ‘a punitive element is now evident. Verbal reminders and reprimands, even “violation letters” are used’. But Gould makes what seems to be a valid point that ‘[s]taff who feel threatened and insecure will not give their best’.
An analysis of the use of language in influencing the behaviour of HCWs was investigated by Cole (2015), examining hand hygiene policies across 359 NHS Trusts in England. The results noted words that recurred with a high frequency in texts: ‘must’, ‘should’, ‘will’, ‘responsible’, ‘compliance’ and ‘audit’. The author states that such words ‘suggest a tone that is authoritative and unyielding. This creates a fractured relationship between those who produce policies and the health-care workers who need to comply with them’ (Cole, 2015: 156). This is a point of view that I disagree with. For example, it is appropriately ‘authoritative and unyielding’ that motorists must drive on the left in the UK. Similarly, if HCWs choose not to undertake basic hand hygiene procedures to protect their patients from possibly fatal infections, perhaps they are in the wrong job.
The National Institute for Health and Care Excellence (NICE, 2014) guidelines on infection prevention and control state: ‘An alcohol-based handrub should be used for hand decontamination before and after direct contact or care, except in the following situations when soap and water must be used: when hands are visibly soiled or potentially contaminated with body fluids or when caring for patients with vomiting or diarrhoeal illness, regardless of whether or not gloves have been worn.’
An understanding of how hand hygiene can prevent infections should not be limited to HCWs, but extended to patients, whose hands may also become transiently or persistently infected with microbes. An American study (Kundrapu et al, 2014), compared the effectiveness of soap and water with an alcohol-based hand rub for the removal of Clostridium difficile spores from patients' hands. It concluded that soap and water washing was effective but alcohol hand rub was not. The authors also made the important point that most patients are unaware of the fact that alcohol is ineffective at killing C. difficile spores.
Finally, it is worth remembering, for both HCWs and patients, that handwashing can save lives.