The Hand Hygiene Dilemma

Edition: September 2013 - Vol 21 Number 09
Article#: 4327
Author: Laura Thill

The numbers don’t look good. Each year, 3.8 million infections occur in long-term-care facilities, leading to 200,000 hospital admissions, 380,000 deaths and $2 billion in related healthcare costs, according to Timothy Wiemken, PhD, MPH, CIC, assistant professor of medicine and assistant director of epidemiology and biostatistics at the University of Louisville, School of Medicine.

The list goes on:

• 75 percent of C. difficile cases surface in nursing homes. (Making Healthcare Safer, Stopping C. difficile Infections, CDC Vital Signs, March 2012)

• A norovirus outbreak can cost a facility as much as $48,000. (U.S. National Institutes of Health, Booz Allen Hamilton)

• Reimbursement for care due to healthcare-associated infection is being eliminated and can lead to penalties for the facility.

The concerns regarding healthcare-associated infections in long-term-care settings are very similar to those in acute care settings, Wiemken points out. However, the extended length of stay associated with long-term-care settings tends to exacerbate these issues, he adds. “By the year 2030, the elderly population (age 65 and older) is expected to reach 72 million people,” he says, noting that the long-term-care population will, in turn, grow exponentially. “As long-term-care grows, if infection control practices, such as hand hygiene and surface decontamination, do not improve, the rates of infection, hospital readmissions, costs and deaths will continue to rise.”

The importance of hand hygiene

Experts agree, proper hand hygiene is key to reducing the spread of infection in long-term-care settings. “Hands should be washed before and after any patient or resident contact, as well as after cleaning and removing one’s gloves,” says Wiemken, stressing that “effective hand washing techniques should be used with every hand washing.

“When hand hygiene and cleaning, sanitization and disinfection procedures falter, the risk of infection rises,” he continues. “Transmission of multi-drug resistant (MDROs) and epidemiologically important organisms (primarily bacteria and viruses) can spread from person to person through the air, hand-to-skin contact and hand-to-surface contact. The chain of infection occurs when pathogens are released from an infected source (via coughing, sneezing, etc.), transmitted via hands or surfaces, and then picked up by a susceptible host. The [result] is colonization and/or infection with one of these organisms, [which] leads to significant morbidity and mortality for the already ill (immune-compromised) patient in the presence of infection. Even if the patient is only colonized with one organism, this can lead to other facilities not accepting the patient if they need to be transferred. Some facilities will not accept patients colonized with MDR organisms.”

Together with hand hygiene, caregivers should ensure that all surfaces in the patient environment are “cleaned for health, going beyond aesthetic cleanliness,” Wiemken points out. Not only should caregivers remove visible soil, it is imperative they use antimicrobial products designed to kill 99.99 percent of infection-causing pathogens common in healthcare settings.

Increasing the awareness

It’s not that long-term-care administrators and caregivers don’t care about infection control. But sometimes they are less aware of the importance of certain best practices, such as hand hygiene, than one might assume. And, it’s easy for busy staff workers to forget to wash their hands as frequently as they should. “Healthcare workers in long-term-care [settings] are committed professionals who are dedicated to caring for their patients and residents,” says Wiemken. “While they are highly educated in many aspects of patient care, many are less familiar and have less access to education and training focused on infection control practices like hand hygiene and environmental disinfection. Unlike acute care settings, some long-term-care facilities (particularly skilled nursing facilities) do not employ infection preventionists to raise and maintain awareness of proper hand hygiene and sanitization procedures. This lack of knowledge has resulted in 15 percent of long-term-care facilities receiving citations for infection control, and putting patient and resident health at risk.”

By educating their customers about how infection-causing microorganisms can be transmitted from one person to the next – as well as how hand hygiene and surface decontamination can help prevent infections by killing the microorganisms before they can be transferred from the source to the host – distributor sales reps can keep them on track, he continues. “In particular, reps should educate facilities about how to prevent the spread of C. difficile and Norovirus, which are threats to the susceptible elderly population in long-term care facilities,” he explains. “It is also important to keep in mind that both [hand hygiene and surface decontamination] are critical. Without hand hygiene, hands will become contaminated and germs will transfer to healthcare surfaces. And, without surface decontamination, surfaces will become contaminated and germs will transfer to the hands of staff and patients/residents. Infection control practices are not complete unless both hand hygiene and surface decontamination practices are followed. With ever increasing rules and regulations, coupled with limited infection control prevention resources, a rep well versed on these rules and regulations can provide a valuable resource by offering training and in-servicing programs.”

A variety of hand hygiene and surface disinfection products are available to long-term-care facilities, according to Wiemken. “It is important that all products used are approved by the Centers for Disease Control and Prevention (CDC), the Environmental Protection Agency (EPA) and the Food and Drug Administration (FDA),” he says. The CDC specifically states that healthcare workers should only use soap and water or ethanol based products. When hands are visibly dirty, contaminated or soiled, the CDC recommends washing with non-antimicrobial or antimicrobial soap and water. If hands are not visibly soiled, facilities should use an alcohol-based hand sanitizer to routinely decontaminate hands.” (Source: Guideline for Hand Hygiene in Health-Care Settings, CDC).

Working with customers

Reps can provide a service by initiating a discussion with their customers about the value of adhering to infection prevention protocols. For starters, they should ask several probing questions, such as the following, Wiemken recommends:

• “What are your biggest challenges when it comes to infection in your facility?”

• “Is there a particular pathogen or infection you struggle with in your facility?”

• “Have you had C. difficile or Norovirus outbreaks at your facility? If so, what methods have you used to manage those outbreaks, and how effective were they in containing them?”

• “What practices for infection prevention do you currently employ in your facility?”

• “How does your facility measure compliance to proper infection control procedures? How often is this done and by whom?”

• “How do you ensure your staff has ownership – or at least buy-in – with regard to each infection control activity?” When staff feel part of the care continuum, they reportedly are more likely to employ proper procedures vs. just complying with another rule.

• “Who makes decisions regarding which products to use? Do the decision makers provide evidence to support their choices?”

• “How often are products re-evaluated? What is the process to bring in new products?” (Can the rep assist in this process?)

• “Is your current cleaner/disinfectant EPA-registered to kill the pathogens you’re most worried about? If so, does it kill it quickly? What is the

kill time?”

• “Does the product keep surfaces wet long enough to meet that kill time, or does it require re-application?”

Cost is always an issue for financially strapped long-term-care facilities, so it should be no surprise if administrators complain that ready-to-use products are too expensive. Sales reps should remind them that such products help reduce the risk of error occurring by taking the guesswork out of preparation/dilution, Wiemken points out. Additionally, because ready-to-use products don’t require mixing, labeling or refreshing, they save staff time.

“Residents’ families evaluate facilities based on appearance and odor,” he continues. “Therefore, sanitization and cleaning practices play a critical role in improving the facility’s image.” They also help the facility prepare for state inspections and “the scrutiny of re-hospitalization rates expected by the Affordable Care Act,” he says. (Source: By outlining CDC and EPA guidelines and identifying “gaps in fighting the most important infectious organisms,” sales reps can help their customers select products that may not be on corporate contract, but provide optimal solutions for their facility, he adds.

“[In the future], patient and family-centered hand hygiene will be one of the most important interventions in long-term-care settings,” says Wiemken. “Patients often auto-inoculate themselves with organisms from the environment, and often by touching anything (other people’s hands, family members, contaminated surfaces, etc.). If we can somehow instill the importance of self-hand hygiene to patients and family members, much of the transmission can be cut down.” Educating long-term-care customers – and they, in turn, educating their patients and their patients’ families/visitors – “will be incredibly useful for everyone,” he notes.

Editor’s note: Repertoire would like to thank Clorox for its assistance with this piece.