Hand hygiene: Two hundred years after Semmelweis we still have work to do

In the mid-1800s, Dr Ignaz Semmelweis recognized that pregnant women who delivered in the care of physicians and residents had more infections than those cared for by midwives.[1] He also recognized that doctors often went directly to the delivery suite from the autopsy rooms. Against great opposition, he initiated a hand-washing policy for the physicians and residents before they attended deliveries. 

Infection rates plummeted, but the doctors were skeptical, and Semmelweis was eventually forced from his position. Hand washing stopped, and rates of infection climbed. It was another 50 years before the importance of hand cleaning in the prevention of infections in health care was recognized. 

Prior to 2010, BC health authorities had developed a wide variety of hand hygiene programs with varied standards and requirements. In 2010, the Provincial Hand Hygiene Working Group was formed to develop and implement a provincial hand-hygiene program. The group has undertaken a number of initiatives including the following:

•    Auditing of hand-cleaning compliance.
•    Surveying health care workers to capture perceptions of hand hygiene strategies and compliance. 
•    Developing education modules and best practice guidelines. 

All of these initiatives were focus­ed on health care workers in health authorities, but are just as relevant for physicians in community practice. Since April 2011, quarterly audit data for hand-cleaning compliance in BC acute care facilities has been posted publicly on the Provincial Infection Control Network website (www.picnet.ca). The latest data show that there have been statistically significant im­provements in hand hygiene over the past 2 years, but also that physicians lag behind other health care workers in cleaning hands and physicians are more likely to clean their hands after patient contact than before contact with patients (Figures 1 and 2).[2]

In 2012 and again in 2013, two surveys were conducted in health authorities, exploring health care workers’ perceptions of hand hygiene. A total of 13422 health care workers participated in 2012, and 10200 in 2013. Physician participation in both surveys was limited, with only 266 (2%) physician responses in 2012, and 213 (2%) in 2013. The Table summarizes the comments from physicians about obstacles to hand hygiene and suggestions for better compliance, which were similar to comments heard from other health care workers.

Health authorities are responding to these results by improving infrastructure to support hand hygiene, including adding more point-of-care dispensers and accessible sinks. However, the more formidable challenge is changing individual perceptions and ingrained habits. As an integral part in the health care system, physicians have an opportunity to show commitment to patient safety by embracing hand cleaning both before and after contact with a patient or a patient’s im­mediate environment. This approach is simple and effective—Semmelweis would approve. 

With a new cohort of residents in hospitals, clinics, and other care settings, now is the time to model appropriate hand-hygiene behavior for the next generation. Cleaning hands protects both health care workers and patients. You can visit www.picnet.ca for more information on how to make hand hygiene an integral part of your health care practice.
—Elizabeth Bryce, MD, FRCPC 
—Bonnie Henry, MD, MPH
BC Provincial Hand Hygiene Working Group