ALMOST a third of doctors and nurses don’t want their patients to remind them to perform hand hygiene, a Swiss study has found.

The study, of 277 doctors and nurses, also found that 27% believed it was not part of the patient’s role to ask about hand hygiene, and that 37% would not agree to wear a badge inviting patients to ask about hand hygiene. (1)

Seventeen per cent of health care workers (HCWs) who responded to the survey believed that patient reminders would be upsetting, and 27% felt it would be humiliating.

“The relatively low rate of endorsement is partly explained by the negative feelings associated with disclosing omission”, the authors wrote. “HCWs may prefer to keep patients in relative ignorance regarding appropriate hand hygiene behavior to avoid delicate situations.”

Professor Lindsay Grayson, director of Hand Hygiene Australia, and director of the Infectious Diseases Department at Austin Health in Melbourne, said it was no surprise that HCWs had misgivings.

“You are being ticked off”, he said. “If it were me, I’d feel frustrated that I had to be reminded, but not angry with the patient.”

Professor Grayson said that overall, trials in Australia that relied on patient prompts had not had great success, mainly because patients depended on HCWs for their care and did not want to be rude to them.

Although Australia’s National Hand Hygiene Initiative endorsed patient input, it preferred to avoid the “slightly confrontational path of patients ticking off health care workers”.

“Hand hygiene is the responsibility of health care workers and it’s up to us to get it right”, Professor Grayson said. “We should welcome it when patients do remind us, but the system should not depend on it.”

MyHospitals data on hospital staff adherence to hand hygiene procedures show there is still room for improvement. One in five Australian public hospitals is yet to reach the 70% national benchmark for hand hygiene, according to the data released in March. (2)

Professor Frank Bowden, a senior staff specialist in Infectious Diseases at the Australian National University, flagged the problem in his 2011 book Gone viral: the germs that share our lives.

Professor Bowden wrote that he was constantly amazed by his colleagues’ lack of concern for infection control.

“Adoption of hand antisepsis is often thwarted by the intransigence of senior and influential clinicians”, he wrote.

Professor Grayson agreed that doctors still lagged behind nurses in hand hygiene, but said there had been significant progress in recent years.

He said further change hinged on education and on making hand hygiene easy. “You need to make it a habit and the best analogy is like a seat belt where you don’t think, you just do it”, he said.

“The College of Surgeons recently announced no one can do surgical training unless they pass hand hygiene credentialing education. One of our aims is to have an online educational requirement for the annual registration of all health care workers.”

Professor Grayson also noted that alcohol rubs had come a long way in the past 5–10 years and now included skin softeners, which had made a huge difference to the practical application of hand hygiene.

“We are changing 200 years of health care practice in the space of a few years”, he said. “The National Hand Hygiene Initiative is the most successful national program worldwide thanks to its systematic approach.”

– Amanda Bryan

1. Arch Internal Med 2012; Online 3 September
2. Australian Institute of Health and Welfare. Hand hygiene information available on MyHospitals (media release)


Posted 10 September 2012

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13 thoughts on “Doctors reject hand hygiene reminders

  1. John Stokes says:

    It is hard to believe little has changed in over a century since Ignaz Semmelweiss in 1847 discovered if you don’t wash your hands patients die. When he discovered this he did not know about bacteria. We do. We use weasel words when we talk about this such as “nosocomial infection”, “cross-infection”, “infection control measures” etc., when we should be saying “not washing hands kills patients”.

    As doctors we should not be dishonest with ourselves and each other and we should be the ones who champion hand washing as a life saving measure. But then again, Ignaz Semmelweis was driven out of the hospital he worked at because of his discovery. Frankly I am happy to be reminded that washing my hands might save someone’s life. In a busy day it is too easy to be complacent and a little help may be a good thing.

  2. Tom says:

    As doctors we want patients to be responsible for their own health and want them to take responsibility for their health outcomes as much as possible. So why would nearly one third of us be upset or humiliated if reminded of one of the most basic and effective steps that would achieve reduction in acquired infection? Isn’t this what all patients should be doing?

  3. Lynton Giles says:

    It is the responsibility of health care workers to wash their hands routinely without the necessity of having to be reminded. All practitioners should remember the first rule of health care is to “do no harm”.

  4. Jules Black says:

    A few years ago when there was a high profile fatal case of meningococcal disease following a young lass’ hospital visit to a friend who already had the disease, it was clear that cross-infection and the principles of barrier nursing were just not followed (or even known by the staff concerned). Semmelweis and Florence N. would have rocked in their graves, as they say. A patient of mine saw me around that time for a regular checkup. She was an extremely high-ranking person in the field of state health. She asked me if I had any thoughts on the matter and I told her how slack nurses and doctors are becoming about handwashing and barrier nursing. My own practice nurse concurred with her own observations from part-time agency nursing.
    I haven’t seen that patient since, but subsequently I was pleased to see signs going up in public hospitals plus more obvious and available skin cleansers at multiple points in wards etc.
    It sounds from this survey that we health professionals are getting slack again.

  5. Rodney says:

    Hand hygene aside an equally great risk of cross infection is the indiscriminate use of gloves or rather the failure to remove contaminated gloves immediatly on leaving the bed side and certainly prior to the use of the telephone, computer, pens, notes, door handles etc etc. Look in any ED and all staff wear gloves virtually all the time – count on the fingers of one hand appropriate and timely removal.

  6. Max King says:

    It’s a K.I.S.S. problem that should eschew euphemisms (or weasel words, a la John Stokes); dirty hands are killers.
    Provision of hand wash lotions in prominent and practical places around wards and in doctors’ offices should provide the goads that patients would otherwise be expected to give.

    As an aside, I was amused by the statement in the article ” it was not part of the patient’s role to ask about hand hygiene”. That’s right – the patient’s role is to be sick and patient.

  7. Anonymous says:

    As a nurse, I always wash my hands following our protocol of the 5 moments (before touching the patient, before aseptic technique or procedure, after touching the patient, after coming in contact with body fluids, after touching the patient surroundings). Off course, this includes before and after donning gloves. As a patient I would like to see the nurse or doctor do the same – it will be for the peace of my mind as health professionals you really do not know what is on your hands. Alcohol hand washes at prominent places (foot of bed, at the entrance of the room, ward, hand basins in every room) are great. As HCW we should put ourselves in the other foot to see how it feels like when you may be compromised by something as simple as hand hygiene.

  8. Sue Ieraci says:

    Important topic, but let’s be realistic: “It is hard to believe little has changed in over a century since Ignaz Semmelweiss in 1847 discovered if you don’t wash your hands patients die.” Not true – an enormous amount has changed in the 30 years since I started practice – from gloves, to washing to alcohol lotion. Not perfect, but a different world to a few decades ago.

    A few years ago when there was a high profile fatal case of meningococcal disease following a young lass’ hospital visit to a friend who already had the disease, it was clear that cross-infection and the principles of barrier nursing were just not followed (or even known by the staff concerned). Jules Black – this girl did not contract the meningococcus from the patient, but from her boyfriend – who travelled with the patient and became an asymptomatic carrier.

    Hand hygiene is important, and is being empahsised more than ever before, but there is no need for dramatic exaggeration.

  9. John Stokes says:

    Sue, I am not sure how close you get to patients and the wards but in my experience everyday many doctors won’t, don’t wash hands and then continue to behave in the most appalling way about this. Ask any medical student what they see on ward rounds, in surgeries and at the bedside. The simple truth is we don’t readily apply his simple technique in our daily work. It is not an exaggeration just the truth.

  10. Sue says:

    John Stokes – perhaps the inpatient ward environment needs more focus. In ED, where we get very close to patients (especially during times of overcrowding), gloves, sinks and alcohol gel are everywhere. My own practice has changed enormously over three decades. ED work is very visible and auditable. It must be time to focus on wards and ward rounds. Are you part of a campaign to improve, John?

  11. mel says:

    Having had two recent stints in hospital I am quite astonished that no-one facilitates THE PATIENT being able to clean their hands, especially a patient who is unable to get out of bed or who cannot reach the bottle of stuff at the end of the bed. No-one seems to talk about this but I think it is quite an issue along with health professionals cleaning their hands.

  12. Ediriweera Desapriya says:

    Clear evidence of clinical benefit from hand hygiene was first reported in 1840.Great Hospital in Vienna in the 1840s instituted hand disinfection with chlorinated lime and after implementation of this hand hygiene protocols hospital maternal morbidity decreased significantly (1). It is difficult to understand why our health care community cannot apprehend the significant clinical benefit of hand hygiene?

    (1). Rotter ML. Semmelweis’ sesquicentennial: a little noted anniversary of handwashing. Curr Opin Inf Dis 1998; 11: 457-60.

  13. Anonymous says:

    My doctor admitted to NOT washing her hands before a skin-to-skin examination and said a few germs will not do any harm AND stated she will not change her practice as she is clean.

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