Research Article by Heather Dieterle
Don’t Get Caught Germy Handed: Be Aware, Wash with Care
In one health care setting, like a doctor’s office, patients see their health care professionals constantly use warm water and soap to wash their hands before and after they touch their patients. On the other hand, in hospitals patients and their families watch their medical professional use hand sanitizer constantly and never actually watch them wash their hands with warm water and soap. Who’s to say the bottle of hand sanitizer is correct when it says the contents kills 99.9% of bacteria, so why would it be that medical professionals trust a label and use this product so frequently? According to the Global Handwashing Partnership, they state, “In recent years, handwashing with soap and other forms of hand hygiene have been gaining recognitions as a cost-effective, essential tool for achieving good health and nutrition. Now that its effectiveness is no longer in question, the main focus is on how to make handwashing universal” (globalhandwashing.org, 2017). As a former nursing student I have been drilled with enter and exit a room using hand sanitizer to clean my hands. I sit here and try to raise the question of why this is so pressed in hospital settings. I know, as a patient stand point I enjoy seeing my medical staff using warm water and soap as opposed to sanitizer when entering my room. I can understand the fact of when exiting the room or in an emergency situation to use hand sanitizer however when a non-emergency situation arises I believe we, as medical staff, should be using warm water and soap in replace of hand sanitizer. I try to raise this question primarily because I care about giving my patients the best care I can give them and if that means I have to spend fifteen seconds using a sink I will.
Hand Washing History
“Hand hygiene is now regarded as one of the most important element of infection control activities. In wake of the growing burden of health care associated infections (HCAIs), the increasing severity of illness and complexity of treatment, superimposed by multi-drug resistant (MDR) pathogen infections, health care practitioners (HCPs) are reversing back to the basics of infection preventions by simple measures like hand hygiene” (Mathur, 2011). Hand washing is something we learn around first grade, I can remember since I was little about being taught the ‘sing happy birthday’ to yourself rule. Fifteen seconds that is all it takes it effectively wash your hands. According to Markel, he states, “nevertheless, approximately 5% to 10% of all hospitalized patients in the developed world acquire infections from health care workers who forgot to wash their hands” (Markel, pg. 447). Although these percentages are fairly low, they should technically be much lower than they are currently. 5-10% is considerably high due to the fact that this hospital acquired diseases can be completely prevented. Ignaz Philipp Semmelweis, “described as the “savior of the mothers”, Semmelweis discovered that the incidence of puerperal fever (also known as “childbed fever”) could be drastically cut by the use of hand disinfection in obstetrical clinics. Puerperal fever was common in mid-19th-century hospitals and often fatal” (en.wikipedia.org). Semmelweis, made a renowned breakthrough in the history of hand washing and what would become a hero act of saving millions of lives. Also according to Markel, “hand hygiene is a relatively new wrinkle in the long history of disease and health. It did not become a bona fide medical prescription until 1847 when Ignaz Semmelweis began exhorting his fellow physicians at the famed Vienna General Hospital (Allgemeines Krankenhaus) to wash up before examining women about to deliver babies” (Markel, pg. 447-448). For something that is such second nature in the medical field today was something that completely was ignored for a very long period of time in history. A point in hand washing history, there was a time where surgeons did not know the efficacy of washing their hands before placing them into someone’s body. Another statement made by Markel that stood out to me is “incorporating the habit of frequently washing our hands in our daily lives is a simple but powerful health policy we can all wrap our hands around, provided there is plenty of water and a bar of soap between them” (Markel, pg. 451). This statement is proof of how easy it is to have hand washing in our daily activities, to me hand washing is very important piece of day to day life. The author, Mathur states “There are two types of microbes colonizing hands: the resident flora, which consists of microorganisms residing under the superficial cells of the stratum corneum and the transient flora, which colonizes the superficial layers of the skin, and is more amenable to removal by routine hand hygiene” According to the Center for Diseases Control and Prevention (CDC) states, “it is estimated that washing hands with soap and water could reduce diarrheal disease-associated deaths by up to 50%. Researchers in London estimated that if everyone routinely washed their hands, a million deaths a year could be prevented. A large percentage of food borne disease outbreaks are spread by contaminated hands. Appropriate hand washing practices can reduce the risk of food borne illness and other infections. Hand washing can reduce the risk of respiratory infections by 16%. The use of an alcohol gel hand sanitizer in the classroom provided an overall reduction in absenteeism due to infection by 19.8% among 16 elementary schools and 6,000 students” (cdc.gov, 2013). With these statistics alone, the spread of disease can be decreased significantly.
Hand Sanitizer History
Hand sanitizer has become a widely known method of hand washing. These are alcohol-based gel products that allow for quick hand hygiene when there is not time for warm water and soap. According to Microchem Laboratory, they state, “hand sanitizers do not serve as a replacement for thorough hand washing. Instead, they are thought to bring consumers some of the benefits of hand washing when hand washing is not practical” (microchemlab.com, 2017). Hand sanitizer was made to be a quick efficient way to try to get bacteria off of hands while in a fast paced environment. “When hands are not visibly soiled, an alcohol based hand rub should be routinely for decontaminating hands. Before having direct contact with patients” (Mathur, 2011). Mathur states this in their article, I think the continuation of the paragraph goes on to say when to use hand sanitizer which is a good thing to know as someone who works in a health care field. Also stated by Microchem Laboratory, “the relationship between hand sanitizer use and reduced illness has not been firmly established by epidemiological studies, but several laboratory studies suggest hand sanitizers help to prevent infections by killing transient pathogenic bacteria” (microchemlab.com, 2017). If hand sanitizer has not been proven to reduce illness why is it so firmly pressed in schools, airports and especially in hospitals? According to Haas and Larson, “the increased use of alcohol-based hand sanitizers at many health care institutions has made hand hygiene more convenient and less time-consuming. Hand sanitizers reduce the need for sinks. The dispensers are small and can be made accessible at every stage of patient care; some dispensers can be worn or carried in a pocket” (Haas & Larson, pg. 41). Hand sanitizer, to me, seemed to be made for convenience and only somewhat for effectiveness. The authors Reynolds, Levy, and Walker state in their article Hand Sanitizer Alert, “some products marketed to the public as antimicrobial hand sanitizers are not effective in reducing bacterial counts on hands. In the course of a classroom demonstration of the comparative efficacy of hospital-grade antimicrobial soap and alcohol-based sanitizers, a product with 40 percent ethanol as the active ingredient was purchased at a retail discount store” (Reynolds, Levy & Walker, pg. 48). Burton, author of Wall Street Journal (online) states, “the Food and Drug Administration is proposing a requirement that markers of antibacterial sanitizing products submit data on safety and effectiveness if they want to stay on the market” (Burton, pg. 1). Hand sanitizers are monitored by the FDA, I think what the FDA is asking of hand sanitizer production companies is only to ensure the safety of the consumer. For hand sanitizer to be effective it needs to have at least in the minimum of 60% alcohol based, hospitals should be aware of this and determine if their hand sanitizer product is effective or not.
Barriers to Hand Hygiene
With any type of issue, there are always barriers in the situation. Hand hygiene is no different. According to Haas and Larson, barriers to hand hygiene, “a lack of access to sinks, a lack of time, dry, chapped skin on hands, ignorance, the high cost of products and initiatives, a divided health care culture, and insufficient personal accountability” (Haas & Larson, pg. 42). For most of these barriers reported, I noticed that more than half have the solution of using alcohol-based hand sanitizer was a potential solution to the barrier. I was able to find a very interesting article on the internet about 11 different barriers to hand hygiene compliance. According to Rodak, “time pressure is one of the biggest reported barriers to hand hygiene compliance among healthcare workers, according to a study in Infection Control and Hospital Epidemiology” (Rodak, 2013). This author also states “in a survey, the participants identified 11 barriers to compliance: ‘I hurry/emergent patient conditions’ at 45.5%, ‘I don’t see any dirt/I think it’s not dirty’ at 24.4%, ‘I forget’ at 15.4%, ‘It is inconvenient’ at 13.8%, ‘I don’t care’ at 8.1%, ‘I’m lazy’ at 5.7%, ‘I wear gloves/no direct contact with patients’ at 4.9%, ‘There are adverse effects of soap/cleanser’ at 4.9%, ‘It wastes time’ at 4.1%, and lastly ‘My hands are clean’ at 2.4%.” (Rodak, 2013). I think all 11 of these answers to ‘hand washing barriers’ are completely wrong answers. I do not see how someone could determine whether or not they will wash their hands based on if they see dirt or not. I can understand the largest answers being in a hurry or emergent patient conditions however they still at the minimum use of alcohol-based hand sanitizer.
Benefits to Hand Washing
As with many other things, hand washing has its own benefits. According to Morgan, she states benefits of hand washing are “reduces risk in medical settings, lowers risk of diarrhea and intestinal problems, prevents eye infections, and lowers respiratory infection risk” (Morgan, 2017). The most important benefit that I see through my eyes is the reducing the risk in medical settings. According to the author, “hand washing is a simple yet vital behavior in hospitals and other medical facilities. Its importance was first realized in a Vienna hospital in the 19th century. Maternity patients were dying at a high rate. Dr. Ignaz Semmelweis started ordering his staff members to wash their hands before treating the patients, drastically lowering the death rate as a result. The transfer of bacteria from cadavers to the patients from the staff’s hands was the culprit in the deaths. Ensuring that today’s medical professionals make hand washing a priority is essential” (Morgan, 2017). I believe this is the most important benefit because stopping the spread of disease and bacteria from caregiver to the patient. Just like hand washing, hand sanitizer also has benefits. According to the Minnesota Department of Health, “waterless hand sanitizer provides several advantages over hand washing with soap and water. However, they are not effective if organic matter (dirt, food, or other material)” (health.state.mn.us, 2016). Also according to the same site, the benefits of hand sanitizer are “require less time than hand washing, act quickly to kill microorganisms on hands, are more accessible than sinks, reduce bacterial counts on hands, do not promote antimicrobial resistance, are less irritating to skin than soap and water, some can even improve condition of skin” (health.state.mn.us, 2016). These benefits help give hand sanitizer a good reputation however I still personally believe that hand washing is much better for the health of a hospital patient. On the other hand, hand sanitizer has known disadvantages along with its benefits. According to livestrong.com, hand sanitizers disadvantages are “cleaning effectiveness, endocrine system disruption, danger to children, and flammable products” (Moore, 2017). The biggest disadvantage to hand sanitizer of these I believe is the cleaning effectiveness. According to Moore, she states, “using hand sanitizers does not replace hand washing, as explained by the Capital Region Board of Cooperative Educational Services (BOCES). If hands have visible dirt, these sanitizers don’t remove it very well. When hand sanitizers are used in schools or other facilities, the budget still must include money to buy soap. Additionally, consumer antiseptic use has not been demonstrated as being more effective than soap and water in any place other than a health care setting” (Moore, 2017). When hand sanitizer is used in the wrong aspect and wrong time can lead to the spread of bacteria and disease to patients in hospitals as well as to healthy people which then can also spread to those who may even just have a cold. The spread of infection is rapidly increasing in the hospital setting which is sad because it is something that can be prevented, this topic is very important to the medical field and needs to be a topic and subject that is talked about more than it is. I believe that this topic is one of the most important pieces one learns when in the medical field.
Hand Sanitizer in Clinical Setting
When you hear an “alcohol-based” product hand sanitizer some people may fret at the thought of giving this product to a child or someone who is an alcoholic. The accessibility of alcohol-based sanitizer is easy to obtain, however it is even easier to receive it in a hospital based setting. A study done states, “a 46-year old man with a medical history significant for bipolar disorder, chronic hepatitis C, type 2 diabetes mellitus, and alcohol abuse was treated at tertiary medical center after being found unconscious in a local grocery store. The patient later said he ingested an unknown amount of alcohol-containing hand sanitizer and mouthwash for intentional alcohol abuse” (Berberet, Burda, Breier, & Lodolce, pg. 2203-2204). As this study went on, this 46-year old man, continued to ingest alcohol-based products that were readily available to him on his hospital floor. When one is addicted to a substance, they go through hoops and bounds to receive the high or drunken state with anything they can find when the one thing they need in their life goes missing. Some parents have a fear of giving their child alcohol-based products because the thought about them ingesting the contents and becoming fatally drunk. According to Poison Control, “a lick of hand sanitizer will not be fatal to a child or anyone else. It does contain alcohol and so should be stored, like other potential poisons, out of sight and out of reach. Should a child actually drink some, call to Poison Control at 1-800-222-1222 immediately” (Soloway, 2018). Parents should be nervous to give their child an alcohol-based sanitizer, also according to Poison Control, “hand sanitizer is not more dangerous than other sources of alcohol in a child’s environment. You wouldn’t let a child have access to beer, wine, liquor or rubbing alcohol. Also, a child should not have access to mouthwash, facial toner, or hair tonics that contain alcohol” (Soloway, 2018). This article continues to talk about the issue by saying “there are two immediate problems with children and alcohol. The first is that it can lower their blood sugar. In extreme, untreated situations, that can lead to coma and seizures…the second problem is that it can make kids drunk. That doesn’t just mean woozy; it means slow heart rate and breathing” (Soloway, 2018). These issues that can arise when a child ingest a large amount of alcohol-based products can be fatal so it is understandable as to why parents are afraid to give their kids these products without supervision.
Effectively Washing Your Hands
There is a right and a wrong way to effectively wash your hands. According to the Center for Disease Control and Prevention (CDC), “hand washing is like a ‘do-it-yourself’ vaccine-it involves five simple and effective steps (wet, lather, scrub, rinse, dry) you can take to reduce the spread of diarrheal and respiratory illness so you can stay healthy” (cdc.gov, 2017). The CDC also gives when you should always wash your hands “before, during and after preparing food, before eating, before and after caring for someone who is sick, before and after treating a cut or wound, after using the toilet, after changing diapers or cleaning up a child who has used the toilet, after blowing your nose, coughing, or sneezing, after touching an animal, animal feed, or animal waste, after handling pet food or pet treats, and after touching garbage” (cdc.gov, 2017). These are all common sense things to wash your hands after doing the activity however most people do not wash their hands after some of these activities. The CDC also gives detailed instructions on how to wash your hands, “wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. Lather your hands by rubbing them together with the soap. Be sure to lather the backs of your hands, between your fingers, and under your nails. Scrub your hands for at least 20 seconds. Need a timer? Hum the “Happy Birthday” song from beginning to end twice. Rinse your hands well under clean, running water. Dry your hands using a clean towel or air dry them.” (cdc.gov, 2017). Although, the CDC’s hand washing method is only five steps (when the study below was made the CDC only had a three step method on their website), the World Health Organization’s (WHO) method has six steps. According to the author Reddy, author of Wall Street Journal (online) states, “the world’s two leading public-health bodies list different instructions on their websites for getting your hands clean. A new study found that the six-step hand-hygiene technique recommended by the World Health Organization (WHO) killed greater numbers of germs than the more general, three-step of the U.S. Centers for Disease Control and Prevention” (Reddy, pg. 1). Considering, now the CDC has a five step method and the WHO has a six step method I would say that they are pretty similar in their effectiveness. Ever want to watch a video on how to effectively wash your hands? Now is your chance!
Safety of Hand Sanitizer
Hand sanitizer is a big thing in the world of hospitals, around every corner and in every room there is a hand sanitizer dispenser that gets filled frequently so it never runs dry. The Food and Drug Administration (FDA), has come to a decision that more research needs to be done on hand sanitizer because they are unaware of its effects and if they are worth the time and money spent on the product. The article states, “to fight infections, hospital workers can hit the hand sanitizer a hundred times or more a day. Now, the government wants more study of whether that is safe and how well it actually fights the spread of germs” (cbsnews.com, 2015). The article about the FDA also states, “The FDA wants companies to provide data from both human and animal studies on absorption rates, blood levels, toxicology, and possible links to cancer and hormonal problems. Regulators say they will use this information to determine safety thresholds for users, particularly vulnerable groups like pregnant women and breastfeeding health care workers. The FDA also wants information about possible links between use of antiseptics and the growth of so-called super-bug bacteria, which are resistant to antibodies” (cbsnews.com, 2015). There are many benefits as noted above in this paper, however as seen here there are some huge concerns with hand sanitizers and will be until further research is compiled.
As I conclude this paper, I still wonder to myself why hand sanitizer is so heavily pushed when there is clear research that there is not enough research to determine if it is safe or not. I believe hand washing should be implemented into hospitals just as it is in doctors’ offices. I do realize that not all hospital rooms have a sink in the main part of the room so I understand some would have the argument that going into a patient’s bathroom to wash your hands with soap and water is invading their space and privacy. However, I do think hospitals would put small sinks at the entrances of patient rooms if hand washing with soap and water was the pushed method of hand hygiene. I also believe that there are times the hand sanitizer should be used but the primary form of hand hygiene that should be performed is for the recommended time and with warm water and soap. Hand sanitizer versus hand washing will always be a prominent debate in the health care field because half of health care pushes one method and the other half pushes the opposite method.