Hand hygiene: a call to ‘all hands on deck’

Charles Delucena Meigs (1792–1869), whilst chair of Obstetrics at Jefferson Medical College, wrote in a publication On The Nature, Signs, and Treatment of Childbed Fevers that ‘Doctors are gentlemen and gentlemen's hands are clean’! However, those supposedly ‘clean gentlemen's hands’ had often come unwashed from the autopsy room to infect a woman struggling to deliver her baby and who would later die of puerperal sepsis. Meigs, though famous for his eponymous syndrome, was also guilty of opposing other major medical advances of his day such as anaesthesia for women in labour. This was despite chloroform's introduction by a fellow obstetrician – Edinburgh's James Young Simpson (1811–70) in 1847. Nosocomial puerperal sepsis was rife in hospitals during the mid-19th century prompting Harvard's Oliver Wendell Holmes (1809–94) in 1843, to pen a classic essay on The Contagiousness of Puerperal Fever with rules for the obstetrician to mitigate this risk including handwashing, changes of clothing and avoidance of autopsies when managing obstetric cases.1 On the other side of the Atlantic, Hungarian Ignác Semmelweis (1818–65) – never one for conducting laboratory research or showing respect to colleagues with whom he disagreed – reduced the Maternal Mortality in Vienna's Allgemeine Krankenhaus in 1847 from 16% to 2% by enforcing handwashing with chlorina liquida in the obstetrics ward.2 There were also other pioneers in the first half of the nineteenth century who advocated for hand hygiene including Semmelweis's own students Routh (1848), Weiger (1848) and Skoda (1849). Another brave advocate was Thomas Watson in London (1842), as these champions suffered ridicule, professional isolation and, in Semmelweis' case, non-renewal of contract.3 Semmelweis was forced to return to his native Hungary and so the women of Budapest became the beneficiaries of his hand hygiene practice where, as in Vienna, he greatly reduced death rate from puerperal sepsis. The word nosocomial is based on the Greek word nosus (disease) and komeion (to take care of) with nosokomeion meaning an infirmary in Greek, and nosocome also being an obsolete 17th century French word for hospital. The word was introduced into English in 1849 but was seldom used until the 1960's.4 The recent development of alcohol-based hand rub (ABHR) as a quick and easy method for of antiseptic hand hygiene has revolutionized infection control practice around the world due to its antimicrobial effectiveness, superiority to antibacterial soaps, availability at the point of care, and skin benefits due to emollients. With the rapid adoption of the five moments of hand hygiene we have seen a dramatic decline in multidrug resistant health care associated Staphylococcus aureus infection rates.5, 6 ABHR provides a major defence against respiratory viruses, preventing community and health care associated transmission of influenza and SARS CoV-2 during the COVID-19 pandemic. The benefits of ABHR instead of the traditional surgical scrub is now gaining acceptance, is included in the WHO's options for surgical hand preparation prior to gloving,7 and has been endorsed by the Australian College of Perioperative Nurses (ACORN). All health services in Australia routinely audit and report their compliance with the five moments of hand hygiene (Fig. 1) as key performance indicators. Surprisingly medical practitioners continue to under- perform compared to their allied health and nursing staff colleagues working in the same clinical areas (Fig. 2). As health care leaders we must set the highest standards and present the right role model for our clinical teams. Source: Hand Hygiene Australia Adherence to Hand hygiene is effective.8 The health service response to the COVID-19 pandemic provides us with a timely reminder of how effective. The Victorian Healthcare Associated Infection Surveillance System (VICNISS) reported significant reductions in the rate of S. aureus bacteraemia, and Clostridium difficile infection, in the April to September 2020 compared with the preceding 3 year April to September periods.9 This improvement suggests that when staff members are motivated to practise hand hygiene and other forms of infection control such as mask wearing and social distancing, hospital acquired infections can be reduced. At the Soochow Children's hospital in China, nosocomial infections declined from 2.56% to 1.39% between 2019 and 2020.10 A large maternal and children's hospital at Fuzhou, Fujian, China also reported a significant decline in both nosocomial infections and multidrug resistant bacteria.11 Sadly today there is still a false perception that ‘Doctors hands are clean’ and this is evident from health service hand hygiene reports that show medical practitioners to be amongst the worst performing healthcare workers (Fig. 2). The failure to change behaviour emanates from the challenges related to the clinical culture and resistance to changing professional behaviour, similar to what occurred in the days of Watson, Wendell Jones and Semmelweis. Failure to observe and practise the five moments of hand hygiene remains more of a cultural problem than one of ignorance, particularly given that successful completion of hand hygiene modules now forms part of many health services' mandatory health professional re-credentialling. Too often, 21st century surgeons and their teams cannot see the microbes they are carrying on their person so, just as in the 1840's, they behave as if they microbes aren't there, but do so at their patients' expense. Errors in hand hygiene performance are related to omission (not doing the right thing), commission (doing the wrong thing) and inition (not caring enough about the implications of omission/commission).12 Surgeons and other clinicians reading this perspective should reflect on whether any inconsistent performance is related to omission, commission, or inition. Let us hope it's not the last of these three! Since the time of Hippocrates (460–370 BC) the word nosokomeion has meant ‘hospital’ so given the dangers of nosocomial (hospital) infections, surgical teams should heed Hippocrates' advice: primum non nocere (‘First do no harm’). This oath still resonates today as a reminder to us all to avoid harming our patients. Hand hygiene protects our patients from nosocomial infections. Open access publishing facilitated by Deakin University, as part of the Wiley - Deakin University agreement via the Council of Australian University Librarians. Eugene Athan: Conceptualization; data curation; formal analysis; investigation; methodology; visualization; writing – original draft; writing – review and editing. David Allan Watters: Conceptualization; data curation; formal analysis; methodology; project administration; resources; supervision; visualization; writing – original draft; writing – review and editing.