Past, Present and Future of Hand Hygiene

Proper hand hygiene is the simplest and most effective way to prevent the spread of infection.

Practicing thorough hand hygiene is an important part of everyday life to avoid catching a communicable disease, and it is even more critical in healthcare environments, where immunocompromised patients are at greater risk to the impacts resulting from catching an infection. In order to understand the next frontier of Hand Hygiene it may be necessary to understand how we got to where we are today.

Ignaz Semmelweis

The importance of hand hygiene in reducing infection rates in medical practices was not always recognized. Dr. Ignaz Semmelweis is widely considered to be the pioneer of antiseptic procedures within healthcare settings and an early champion of hand hygiene. In the 1840s, Semmelweis introduced the practice of handwashing with chlorinated lime solutions, between examining patients. At a time when mortality rates from streptococcal puerperal sepsis (childbed fever) were upwards of 20%, Semmelweis was able to reduce the mortality rate in the obstetric clinic of Vienna’s General Hospital to less than 2%. [1]

Florence Nightingale

Several years after Semmelweis, the Crimean War of the 1850s brought about a new handwashing champion, Florence Nightingale. Conditions in field hospitals were often crowded and unsanitary; it was common at the time for two-times more soldiers to die from diseases acquired in war hospitals than on the battlefield. [2] Nightingale implemented handwashing and other hygiene practices in the war hospital in which she worked and later collaborated with the Sanitary Commission to reform hospitals and healthcare, leading to noticeable reductions in death rates, worldwide. [3]

Robert Koch

Robert Koch was a leading microbiologist of his time, and today is considered one of the main founders of modern bacteriology. He determined the connection between infectious agents and disease, demonstrating that different germs caused different types of diseases. [4] In 1882, Koch discovered the tuberculosis bacillus, followed by the bacillus responsible for waterborne cholera two years later, in 1884.

Louis Pasteur

Louis Pasteur’s work helped to shape the science of microbiology. In his experiments, Pasteur demonstrated that most infectious diseases were caused by germs, and not by “spontaneous generation” as previously thought. Pasteur suggested three methods to eradicate disease-causing micro-organisms, including filtering them out, heating them up, or exposing them to chemical solutions. [5] The latter proved a cornerstone of modern medicine.

Joseph Lister

Expanding on the findings from Pasteur, Joseph Lister pioneered antiseptic surgery with the use of phenols. In the 1800s, post-surgical operations resulted in a mortality rate as high as 80%. [6] In 1867, Lister introduced antiseptics into clinical surgery to effectively reduce infection rates, building on centuries of empiric use of antiseptics. [7]

Alexander Fleming

In 1928, Sir Alexander Fleming revolutionized modern medicine with the discovery of penicillin. The antibiotic was mass-produced for use during World War II, and has since revolutionized modern medicine and saved millions of lives. [8] Conversely, the discovery and mass production of penicillin to treat bacterial infections also marked the birth of the story of antibiotic resistance.

Mass introduction of alcohol-based hand rubs

Alcohol has been used as an antiseptic for centuries; with references to the use of wine in wound dressings dating back as early as the 4th and 5th century BCE. [9] As early as 1363, distilled spirits were used in wound dressings, gaining popularity as the centuries progressed. [10]

Although alcohol, and other antiseptics, had been used for disinfection for decades prior to the 1960s, this solution never reached mass market application in healthcare until the integration of moisturizers in hand disinfectant in the 1960s. Following the addition of moisturizers, alcohol-based hand sanitizers were distributed throughout healthcare institutions, replacing the requirement for frequent hand washing. The faster dry time, and extremely high efficacy rate was a quantum leap in infection prevention.

Hermann Ophardt and the ingo-man® dispenser

While alcohol-based hand sanitizers were gaining in popularity, dispenser systems at the time were prone to leakage. The seals of soap dispensers could not hold against the sanitizers, and instead allowed product to leak onto hospital floors. Following a customer request to solve this problem, Hermann Ophardt prototyped the ingo-man® dispenser. The ingo-man® dispenser was the first dispenser capable of reliably dispensing sanitizers, while also surviving the extreme temperatures of reprocessing in an autoclave. The ingo-man® became the pioneering dispenser for the Euro Bottle concept, and its reputation as the pinnacle of dispensing quality spread quickly. The mass adoption of this dispenser system allowed hospitals to usher in the age of alcohol-based disinfection before each patient visit in Europe.

The rise of antimicrobial resistance

In the years following the introduction of penicillin and other subsequent antibiotics, the number of antibiotic resistant microorganisms has grown. A 2014 report commissioned by the UK government cites a 40% increase in worldwide consumption of antibiotics from the year 2000 to 2010. This increase has caused the amount of deaths linked to antimicrobial resistance to rise to approximately 700,000 worldwide. The study estimates that if current trends were to continue, AMR would be linked to more than 10 million deaths per year by 2050 – making it the leading cause of death, ahead of cancer.

The report cites sanitation and hygiene as one of the key pillars needed to respond to this crisis.

The WHO and the Five Moments

In 2009, the World Health Organization (WHO) responded to the rising need to standardize hand hygiene programs, by introducing the five moments of hand hygiene. The five moments lay the groundwork for hand hygiene regulations and standards around the world.

The five moments are before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings. The five moments are divided into two zones: extended and direct patient environments. The latter is particularly crucial. This is because the majority of all hand hygiene indications occur directly at the patient and during his/her treatment – i.e. at the “point-of-care.”

From the 1960s until today

To respond to the needs from the World Health Organization and the rising challenge of hospital-acquired infections and antimicrobial resistance, the industry has developed a number of solutions since the advent of alcohol-based hand rubs and reliable dispensers. Most notably, dispensers have evolved increasingly toward touchless technologies to increase usage and decrease cross-contamination. Bracket systems and stands have evolved to make hand hygiene more convenient, available, and compliant with the WHO “point-of-care” model. Refill packaging has been improved to become more convenient and hygienic. Materials and surfaces have been improved in order to increase both hygienic properties and visibility for improved compliance. Chemical companies have advanced their formulas and worked with dispenser manufacturers to offer more refined dispensing formats like gels, foams, and alco-foams – all in an effort to improve hand hygiene compliance rates.

The future of hand hygiene

It’s hard to say exactly where the future of hand hygiene lies, but with the all-but-certain mass introduction of 5G we can be confident that we are seeing the early beginnings of a truly IOT-driven world. Both the world of hand hygiene and healthcare have been early adopters of this category to begin with. That’s why OPHARDT Hygiene introduced their first IOT-capable dispensers for healthcare over 9 years ago.

Gathering information from dispensers offers many advantages. Besides the obvious efficiency gains from alerts on fill-levels, battery status and dispenser functionality, it appears that digitalization of hand hygiene in healthcare can usher in the same kind of quantum leap for hand hygiene as the introduction of alcohol-based hand rubs nearly 60 years ago. While the work of Semmelweis and others helped us understand why hand hygiene is so crucial for successful treatment of patients, we often see that true hand hygiene compliance rates in healthcare often still fall below 40%.

With the help of the OPHARDT Hygiene Monitoring System (OHMS), a trial held in Greifswald Germany showed that targeted training – based on data provided from OHMS – can lead to significantly improved quality of hand hygiene (amount dosed per hand hygiene event) and amount of hand hygiene events. The introduction of this system in Greifswald enabled a 30% increase in disinfectant consumption per patient day, which correlated to a 28% decrease in antibiotic treatment days. In the face of rising antimicrobial resistance and staggering numbers of hospital-acquired infections – those are materially significant numbers that represent noticeably better, safer care for patients.

Since the Greifswald trial, the use of feedback systems has further improved the usability of electronic monitoring systems. The use of feedback monitors – which provide healthcare workers with instant feedback on compliance rates on their ward/unit – have been shown to increase hand hygiene compliance without training. New products introducing instant feedback on quality of hand hygiene performance at the time of hand disinfection also hope to push compliance to another level.

Soruces:

[1] Ataman, A. D., Vatanoğlu-Lutz, E. E., Yildirim, G. (2013). Medicine in stamps – Ignaz Semmelweis and Puerperal Fever. J Turk Ger Gynecol Assoc. 14(1), 35-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881728/

[2] Bencko, V., Schejbalová, M. (2006). From Ignaz Semmelweis to the Present: Crucial Problems of Hospital Hygiene. Indoor Build Environ 15(1), 3-7. https://journals.sagepub.com/doi/pdf/10.1177/1420326X06062362

[3] McDonald, L. (2016). Florence Nightingale: Statistics to Save Lives. IJSP 5(1), 26-35. https://www.researchgate.net/profile/Lynn_Mcdonald2/publication/284199975_Florence_Nightingale_Statistics_to_Save_Lives/links/5a6350120f7e9b6b8fd87191/Florence-Nightingale-Statistics-to-Save-Lives.pdf

[4] Alexander, J.W. (1985). The Contributions of Infection Control to a Century of Surgical Progress. Ann Surg 201(4), 423-28. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1250728/pdf/annsurg00110-0033.pdf

[5] Bencko, V., Schejbalová, M. (2006). From Ignaz Semmelweis to the Present: Crucial Problems of Hospital Hygiene. Indoor Build Environ 15(1), 3-7. https://journals.sagepub.com/doi/pdf/10.1177/1420326X06062362

[6] Bencko, V., Schejbalová, M. (2006). From Ignaz Semmelweis to the Present: Crucial Problems of Hospital Hygiene. Indoor Build Environ 15(1), 3-7. https://journals.sagepub.com/doi/pdf/10.1177/1420326X06062362

[7] Jessney, B. (2012). Joseph Lister (1827-1912): a pioneer of antiseptic surgery remembered a century after his death. J Med Biog 20(3), 107-10.

[8] Alexander, J.W. (1985). The Contributions of Infection Control to a Century of Surgical Progress. Ann Surg 201(4), 423-28. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1250728/pdf/annsurg00110-0033.pdf

[9] Tan, S. Y., Tatsumura, Y. (2015). Alexander Fleming (1881-1955): Discoverer of penicillin. Singapore Med J 56(7), 366-67. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4520913/

[10] Alexander, J.W. (1985). The Contributions of Infection Control to a Century of Surgical Progress. Ann Surg 201(4), 423-28. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1250728/pdf/annsurg00110-0033.pdf