Handwashing: Is a New Normal Possible?

Can something as simple as handwashing prevent the spread of coronavirus disease 2019 (COVID-19)? Today, handwashing is as important as ever. Prevention becomes essential to stopping the spread of the virus because there is no vaccine to prevent it and no treatment for anyone experiencing the illness.

Mitigation is the only tool we have at our disposal to fight this novel virus. Science has consistently proven that handwashing is the only way to prevent viral and bacterial diseases. Healthcare providers know that hand hygiene protocols reduce the rates of healthcare-associated infections (HAIs), yet providers continue to miss opportunities to perform hand hygiene. COVID-19 will have a lasting impact on hand-hygiene practices if we reevaluate what outcome we want to achieve with the provision of education on hand hygiene.

Coronavirus is spread by droplets. So anytime we talk or sneeze or cough, there are droplets that come from our mouth and nose. The virus is on our face, hands from covering our sneeze by habit, or even with the use of tissues. The virus can land on surfaces. If a contaminated surface is touched then one is at risk for contracting the virus via hand contact with their face, nose, eyes, and mouth. During the COVID-19 pandemic, handwashing becomes even more important. How can healthcare providers serve as credible educators for the general population, on the critical issue of hand hygiene, when healthcare providers are not consistently practicing hand hygiene? How can we prevent the transmission of disease when we neglect to provide patients with an opportunity to properly wash their hands?

Healthcare workers now have an increased need to wash hands. Hand hygiene should be completed prior to donning and after doffing personal protective equipment. Healthcare providers are also wearing masks for the duration of their shift in healthcare facilities. Hand hygiene should be performed after adjusting their mask as well.

Healthcare workers have many reasons for not performing hand hygiene. Edmonds, et al includes some of the following reasons for not washing hands: inconvenience, I forgot, I was wearing gloves, lack of education, hands full, skin breakdown, frequent entry into room, and hand hygiene products have a strange odor or leave a film on hands.¹ The reasons for lack of hand hygiene are only important if we use the noncompliance reasons to improve systems such as: promoting hand hygiene, trialing new products, or changing behaviors of healthcare providers.

What can professional development educators and infection control specialists do to encourage hand hygiene? We need to consider what outcome we would like to achieve with hand hygiene compliance.

Have professional development educators and infection control specialists consider the objective of hand hygiene education. Is the objective of hand hygiene education to increase the compliance rates of hand hygiene or is the objective of hand hygiene to prevent the transmission of disease?

If the objective of hand hygiene is to prevent the transmission of disease, then our educational content needs to be redesigned. We need to transform our education programs and campaigns. Education needs to include content related to how easily germs are spread and transmitted in the hospital environment, how healthcare employees contaminate the environment, how the environment is contaminated with social media devices, how staff contaminate themselves, how patients can contaminate their environment.

We need to create educational programs for patients, families, and visitors, as well as staff. Education can no longer be “wash in and wash out.” Professional development educators and infection control specialists need to design educational programs that create a lasting behavior change in all constituents.

The only education that should remain consistent is the procedure for washing hands. The procedure² for handwashing, according to the US Centers for Disease Control and Prevention (CDC), should be adopted in all healthcare facilities. The procedure is:

Wet your hands with clean, running water (warm or cold), turn off the water, and apply soap.

Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails.

Scrub your hands for at least 20 seconds. Twenty seconds can be measured by Singing the song “Happy Birthday” or the “ABCs” 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.

Now is the time to change our educational methods. We need to change our content. We need to get the message out that the goal of hand hygiene is to prevent the transmission of disease. We need to ask staff if they have stopped the spread of your germs today? We cannot just put the handwashing flyer reminder somewhere out there in healthcare facilities. We need to change the signage and location of the information frequently, so the message remains on the minds of the providers. The message needs to be innovative. We need to create educational interventions that promote a change in personal behavior.

A major educational deficit that remains in the healthcare system is patient hand hygiene. How often do we encourage patients to perform hand hygiene while in the healthcare facility? Do we have signage to encourage patient handwashing? Is hand sanitizer available to our nonmobile patients? Do we offer an opportunity for patients to wash their hands before and after meals? After using a bedpan or commode, has the patient been provided with access to soap and water? Is the opportunity available in your healthcare facility for a patient to perform hand hygiene after coughing or sneezing? Are patients offered a chance to wash their hands after a procedure outside their room? Is hand sanitizer or soap and water available to the patient after a physical, occupational, or speech therapy session? Have we taught patients to complete hand hygiene after touching a wound or dressing?

Now is the time to provide education to patients encouraging the patients to ask for an opportunity to wash their hands while a patient in the healthcare facility. We need to educate patients to speak up for access to hand hygiene to prevent the transmission of disease. Access to soap and water or hand sanitizer is a necessity for patients in the healthcare facility. Professional development and infection control specialists can make a difference in the health of our patients. Emphasizing patient hand hygiene can only serve to decrease the infection rates in patients and stop the transmission of disease.

Our methodology for collecting hand hygiene compliance data needs to change. We need to ask ourselves tough questions. Do we truly empower our hand hygiene observers to conduct in-the-moment education with staff? Can all employees stop the line? Do we truly create a culture of do no harm? With the increased necessity for hand hygiene, is now the time to invest in technology to measure hand hygiene compliance? Do we need to begin to measure hand hygiene compliance in the patient population?

In this time of the global pandemic, patients are afraid to return to healthcare settings for routine care, elective procedures, and even emergent life-threatening procedures. Can we convince the public to return to the healthcare system for elective or life sustaining treatment with improved hand hygiene? COVID-19 has changed the world in which we live. Can we respond with increased rigor to prevent the spread of disease? Would you feel safer as a patient or a healthcare worker if we stopped transmitting disease?

Mary Jean Ricci, MSN, RN-BC, is the director of clinical education at Drexel University College of Medicine. She’s also a nursing supervisor at Fox Chase Cancer Center in Philadelphia.

References:

1. Edmonds, M. Landon, E. Larson, E.& Price, C. Infection prevention in hospitals: the importance of hand hygiene. Infectious Disease News. April 2014.

1. Centers for Disease Control and Prevention. Guidelines for hand hygiene in healthcare settings. CDC website. https://www.cdc.gov/handhygiene/index.html