Volume 184 - Issue 5
Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection
Authors: R Michael Whitby and Mary-Louise McLaws
Med J Aust 2006; 184 (5): 253-254. || doi: 10.5694/j.1326-5377.2006.tb00222.x
Published online: 6 March 2006
Published online: 6 March 2006
To the Editor: We congratulate Johnson et al on their article, which illustrates a successful hand hygiene program associated with a fall in transmission of multidrug-resistant organisms.1 Their publication is significant for three reasons:
It is only the second article2 to demonstrate the anticipated relationship between increased hand hygiene and a fall in multidrug-resistant organism transmission;
It again indicates that 100% compliance in hand hygiene is not necessary to significantly improve outcomes;2,3 and
It suggests that environmental contamination with MRSA has little relationship to patient colonisation.
However, the specific aspects of their program that led to success are not obvious, and may not relate to a sustained response to either education or the provision of alcohol/chlorhexidine hand hygiene solution. Alternative explanations include:
The education program and/or overt observation induced a Hawthorne effect on hand hygiene practice;
The screening and treatment program induced the same effect on hand hygiene behaviour; or
The treatment of MRSA carriers reduced the size of the MRSA reservoir and thus the probability of transmission and subsequent colonisation.
Although we agree that the approach of Johnson et al is laudable, without teasing out those causal factors that induce the improvement in hand hygiene in health care workers, it remains expensive to implement and maintain. Moreover, there is no evidence that improved hand hygiene would continue if the alcoholic gel alone remained, without all other aspects of the program. This was recognised in the successful Geneva program on which the protocol used by Johnson et al was modelled. In that study, the authors remained so uncertain as to what elements of the program were causal that they stated:
Whether improved hand-hygiene practice will outlast the intervention remains uncertain; we decided to refrain from testing this issue by maintaining a permanent component of the intervention.2
Evidence currently available4 and soon to be amplified5 suggests that hand hygiene practice in health care workers is simply an extrapolation of their community behaviour. Unfortunately, community hand washing behaviour is not microbiologically founded, being developed on the basis of emotion not science. Both the Austin and Geneva protocols supported the introduction of alcoholic hand gel with strong promotion of specific behavioural elements to induce change in hand hygiene practice. Our findings suggest that alcoholic gel is not pivotal to the improvement of hand hygiene, in that behavioural modelling suggests its effect is relatively small and very dependent on concomitant behavioural change.4,5
The World Health Organization World Alliance for Patient Safety has recently advocated the introduction of alcoholic gel into all hospitals.6 While not denying that this is a step toward improvement, we strongly caution against unrealistic expectations of this single intervention. The hand hygiene practices of health care workers are learned behaviours of childhood, continued as professionals, and reinforced in everyone’s daily lives.4,5 Entrenched, longstanding behaviour patterns will not be changed in a sustained fashion by the introduction of a new hand hygiene product.
References
- Johnson PDR, Martin R, Burrell LJ, et al. Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Med J Aust 2005; 183: 509-519. <eMJA full text>
- Pittet D, Hugonnet S, Harbath S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000; 356: 1307-1312. 0_i1091577
- Whitby M, McLaws M-L. Hand-washing in healthcare workers: accessibility of sink location does not improve compliance. J Hosp Infect 2004; 58: 247-253. 0_i1091579
- World Health Organization. Behavioural considerations. In: WHO Guidelines on hand hygiene in health care (advanced draft). Chapter 15. Geneva: WHO, 2005: 53-57. Available at: http://www.who.int/patientsafety/events/05/HH_Guidelines_10Oct2005_AdvDraft_FINAL.pdf (accessed Jan 2006, no longer available; try http://www.who.int/patientsafety/events/05/HH_en.pdf).
- Whitby M, McLaws M-L, Ross M. Why healthcare workers don’t wash their hands: a behavioural explanation. Infect Control Hosp Epidemiol 2006; 27. In press. 0_i1091585
- World Health Organization. World Alliance for Patient Safety [website]. Available at: http://www.who.int/patientsafety/en/ (accessed Jan 2006).