August 2004 Bulletin

Patient safety tip

My hands are clean—or are they?

By Robert L. Brooks, MD, PhD

The increasing incidence and prevalence of healthcare-associated infections is one of the largest patient safety problems facing our society. Physicians, nurses, pharmacists and public health experts are constantly battling microbial enemies that have a billion years’ experience in mutating to survive. New antibiotics are beneficial, but also bring further resistance as well as tragic complications such as clostridium difficile-associated colitis.

Yet when it comes to the most basic and least expensive of infection control modalities—frequent hand washing—American caregivers continue to fall abysmally short. Direct observational studies consistently show that physicians wash their hands while making hospital rounds one third to one half as often as they should. We visit patients, shake hands, use a stethoscope and hurriedly move on to the next patient, or to the medical record, all the while potentially cross-pollinating disease.

In the March 25, 2004 issue of the New England Journal of Medicine, Atul Gawande, MD, a general surgeon, published an emotionally powerful review of the history of physician hand-washing habits and the difficulty of achieving behavioral change. Only in the operating suite have we established a culture that does not tolerate inadequate cleanliness. We rarely achieve the same standards in our intensive care units and surgical wards.

For this reason, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) required all accredited hospitals to comply with all of the hand hygiene guidelines recommended by the Centers for Disease Control as of January 1, 2004. These guidelines specify that hospital caregivers may not wear artificial fingernails, and they must trim their nails no longer than ”. In addition, hands must be washed between every patient contact. Although every American hospital staff member is striving to achieve these standards, there are many barriers. As physicians, we must believe that staff is watching us—their role models—to see if we walk the walk in addition to talking the talk.

Patients are watching

Our patients are also alert to increasing hospital-associated infections. Media reports leave patients with the impression that too many infections are spread by doctors and nurses. Patients are asking their providers to wash their hands before touching them and noticing when they do not. Of the top 10 Patient Safety Tips published in the AAOS Bulletin of April 2004, only one was submitted by a patient. Ms. Bonnie Wallace of Greensboro, N.C., wrote: “For patients—Keep a pump bottle of hand sanitizer on your bed tray. It serves as a visual reminder for staff to wash their hands or put on gloves.”

The AAOS membership has taken a proud leadership role in patient safety issues. We should also “own” the problem of healthcare-associated infections and set an example for other providers. Let us wash our hands of this issue, and, in so doing, again turn the wrench to improve the safety of our patients.

Robert L. Brooks, MD, PhD, is a member of the AAOS Patient Safety Committee.

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