Hand hygiene MOST CERTAINLY prevents healthcare associated infections
In the first post, he notes: “if puerperal fever was a CDC HAI and clinicians didn't wear gloves, we could still say hand hygiene prevents HAI. However, that's not the current reality.” Well, puerperal fever is a CDC HAI (see here, page 23).
Next he states that CDC defines HAI as CLABSI, CAUTI, SSI and VAP. That’s a true statement, but I think he’s implying that CDC defines HAIs as only those 4 (particularly in light of the paragraph above). Actually, CDC has defined over 30 HAIs (definitions here, page 4).
He goes on to say that the WHO hand hygiene moment #2 (hand hygiene before clean and aseptic procedures) is not part of the CLABSI bundle published by Peter Pronovost. But Pronovost’s article (to which he links) states otherwise:
Per Eli, “Do we really think that interns and nurses practicing hand hygiene on the wards prevents SSIs to any measurable extent compared to pre-operative CHG bathing or peri-operative antibiotics?” Well, to Eli I would say, the next time one of your family members has a surgical procedure, tell the surgical team that they don’t need to perform hand hygiene before touching your loved one’s fresh surgical wound.
He argues that hand hygiene is not a significant component in the causal pathway for HAI, then four paragraphs later goes a step further and states that hand hygiene is not in the causal pathway. While for some HAIs hand hygiene may not be the most important risk factor, it is nonetheless a risk factor and it is indeed in the causal pathway. Then we come to twisted logic. Per Eli, hand hygiene prevents transmission of microorganisms but it doesn’t prevent HAIs. However, transmission of microorganisms is an intermediate outcome that can lead to HAI. It’s like saying: guns don’t kill people, bullets do.
He states that interventions to improve hand hygiene are not used for outbreak control. That’s contrary to my experience. We focused on hand hygiene in almost every outbreak that I managed over two decades as a hospital epidemiologist. In some cases, it was one of our first interventions while we proceeded with the investigation.
His next post focused on how you cannot correlate ward-level hand hygiene compliance with HAIs. Given the relatively small number of observations collected, and the relatively small range of compliance, I agree.
He shows an Ishikawa diagram of factors leading to CLABSI, but it and his subsequent logic ignore the fact that CLABSIs are not just associated with catheter insertion. In fact, we rarely see insertion-related CLABSIs anymore because the CLABSI bundle (which includes hand hygiene!) is so effective. The typical CLABSI now occurs in patients who have had a central line for weeks to months. So, the important factors now are associated with line maintenance (e.g., the line dressing, skin hygiene, minimization of entry into the line for lab draws, etc).
He next estimates how many months of hand hygiene observations are necessary to witness one opportunity where the HCW touches a CVC? But his focus is on how many observations are performed not on how many opportunities exist. I’ve previously estimated that in a 700-bed hospital there are 15 million hand hygiene opportunities per year. Using Eli’s estimates (which I have no reason to doubt), that translates to 30,000 direct manipulations of a central venous catheter yearly. I sincerely hope that every one of those was preceded by hand hygiene, and I suspect almost every hospital epidemiologist and every patient hopes so, too.
I get Eli’s point that trying to precisely measure hand hygiene compliance is dumb. But I think there is value in the process of monitoring hand hygiene because it keeps hand hygiene top of mind. It’s the Hawthorne effect in action. And the past decade or so of all this measurement has made a difference. If I compare the present to when I was a house officer 30 years ago, it’s amazingly different. There was zero focus on hand hygiene in the 1980s. There were many fewer sinks and no alcohol-based products available. We have made enormous progress.
My thoughts on hand hygiene are simple: It’s important. It’s really important. Keep doing it. Keep measuring it. It eventually becomes a habit. And someday, it will be so ingrained we won’t need to talk about it anymore.