Updated: March 24, 2020
Handwashing in healthcare has always been important, and that importance is becoming more recognized due to the urgent need to curtail the spread of the coronavirus. Let’s take a look at where we are today and how we got here over years of scientific discoveries and breakthroughs.
Where We Are Today
The relationship between clean hands and infection prevention is indisputable. The Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene provide detailed advice for healthcare providers and patients. In a nutshell, the guidelines for providers call for handwashing with an alcohol-based hand rub or soap and water in these situations:
Immediately before touching a patient
Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices
Before moving from work on a soiled body site to a clean body site on the same patient
After touching a patient or the patient’s immediate environment
After contact with blood, body fluids, or contaminated surfaces
Immediately after glove removal
The CDC says healthcare facilities should require all personnel to perform hand hygiene in accordance with these guidelines, ensure that personnel use soap and water when hands are visibly soiled, and deliver the supplies necessary for hand hygiene adherence to where patient care is being delivered.
Proper hand hygiene is ground zero for infection prevention. Learn more about Vitalacy’s hand hygiene compliance monitoring technology for healthcare facilities.
How We Got Here
In 1795, in Aberdeen, Scotland, physician Alexander Gordon suggested that workers who had treated women for puerperal fever had somehow spread the disease to other women. He was one of the first to intuit the existence of germs, or something like them. If only he’d known the universe of bacteria, viruses, and fungi that lay beneath everything.
In 1843, Harvard anatomist Oliver Wendell Holmes also cottoned on to the connection between touch and disease: he believed physicians could catch puerperal fever from patients. He also said physicians had a societal obligation to not perform autopsies on women who had died of the fever.
These men were ahead of their time, gifted with futuristic insight. If they could have seen today’s massive infection control campaigns, they probably would have been astonished at their accuracy. Or possibly alarmed. But they also would have been impressed with the sophistication and dedication of today’s hospitals in preventing disease.
For a bit of historical trivia, here’s a look at how hand hygiene evolved over the years.
1846/1847: Vienna, Austria
Ignaz Semmelweis Becomes The “Father Of Hand Hygiene”
Ignaz Semmelweis begins working in Vienna General Hospital. He realizes that women giving birth in the maternity ward run by medical students and doctors have a higher mortality rate from puerperal fever than women giving birth in the midwife-run maternity ward (16% vs. 7%).
While investigating the reason behind the different rates, Dr. Semmelweis discovers that the medical students and doctors — unlike the midwives — often come straight from performing autopsies to the maternity ward. He believes that they spread particles from the autopsies onto their patients.
Dr. Semmelweis mandates that everyone wash their hands with a chlorine solution after performing autopsies. Death rates decline dramatically — from 17% to 3%. His research, along with Wendell’s, distinctly ties handwashing to hospital-acquired infections. Dr. Semmelweis’ “recognize, explain, act” model of infection prevention will be used for centuries.
The Vienna General Hospital handwashing experiment is also one of the first to highlight a challenge that will plague infection control specialists for years to come. Despite the fact that handwashing is shown to decrease infections, many physicians resist adopting handwashing protocols. Why?
They’re pressed for time.
They might resent receiving orders.
They might resent the implication that they’re to blame for a patient’s illness.
1854: Scutari, Italy Florence Nightingale Is The “Mother Of Nursing”
Florence Nightingale, a nurse from Italy, travels to a military camp for British soldiers on the outskirts of modern-day Istanbul. Along with her fellow nurses, she is tasked with caring for soldiers who have been wounded while fighting in the Crimean War.
In the hospital, infections are running rampant. More soldiers are dying from infections like typhoid, typhus, dysentery, and cholera than from battle wounds. Nightingale believes that infections are spreading due to unsanitary conditions — hygiene is being neglected, there are no clean linens, and there is a shortage of soap.
Nightingale instructs nurses to clean the wards, and she begins ordering supplies to keep the hospital sanitary.
She eventually becomes a champion for handwashing in healthcare — but in an indirect way. Most people believed that infections were caused by miasmas (foul odors), and Nightingale begins handwashing and hygiene practices as a way to fight the miasmas. Even though she is aiming to fight the odors, her hygiene practices end up reducing infection.
1906–1915: New York, NY Typhoid Mary Leaves Thousands Sick In Her Wake
Mary Mallon, more commonly known as “Typhoid Mary,” illustrates that hand hygiene is important for everyone who works in a hospital — not just those who care directly for patients.
Mary’s legacy begins when she immigrates to the United States from Ireland, and takes a job as a cook for a family in New York City. While she’s working in the home, 11 people in the house are diagnosed with typhoid fever.
George Sober, a sanitary engineer, investigates the outbreak. He discovers that Mary had worked for eight other families, and seven of those families also experienced an outbreak. Mary does not believe that she is responsible, as she does not have symptoms of typhoid fever, and there have never been other reported cases of “healthier carriers” in the U.S.
After about 3,000 New Yorkers develop typhoid fever in one year — most likely with Mary as the main reason for the outbreak — Mary is sequestered. She is released a few years later, with an agreement that she will not be a cook again.
However, Mary does not keep up her end of the agreement. In 1915, under the name “Mary Brown,” she takes a job as a cook at Sloane Maternity Hospital in New York. She becomes responsible for an outbreak at the hospital that infects at least 25 people, killing two.
1962: Cleveland, OH Researchers Discover Why Nurses Must Wash Their Hands
Researchers in Cleveland publish findings about the transmission of Staphylococcus aureus (S. aureus) infection from nurses to patients.
The researchers refute the widely held belief that S. aureus is airborne, finding that it’s only airborne in about 6% to 10% of cases. Instead, they find that it is almost always contracted through direct touch.
While investigating the transmission of S. aureus, the researchers make shocking observations about the role of clean hands:
54% of newborns who are handled by carrier nurses with unwashed hands become colonized with S. aureus.
There is a 43% transmission rate when non-carrier nurses handle a colonized baby, and then handle an uncolonized one, without washing their hands.
92% of babies who are treated by a nurse colonized with S. aureus with unwashed hands become infected with the S. aureus strain. The percentage is significantly lower for babies handled by nurses who wash their hands — 53%.
In addition to discovering the impact unwashed hands have on the transmission of disease, the researchers also realize how much proper hand hygiene protocols matter.
With antiseptic handwashing, the rate of transmission is reduced to 14%.
The researchers are quick to point out that more work needs to be done. Handwashing reduces transmission by about 50%, but they know it needs to be reduced even further.
1994–1997: Geneva, Switzerland Swiss Hospitals Set A Worldwide Precedent
University of Geneva hospitals aim to improve hand hygiene adherence, emphasizing the role of bedside, alcohol-based hand disinfection.
The hospitals distribute individual-sized bottles of hand-rubbing solution to each ward. They mount custom-made holders to the beds to give healthcare workers easier access to sanitizer.
Workers are encouraged to carry bottles in their pockets, and the hospital makes this easier by creating flat bottles (rather than round) that fit better.
The intervention to improve hand hygiene adherence is multimodal. In addition to making hand sanitizer more readily available, the hospital also hangs posters, educates workers, and provides performance feedback.
Hand hygiene compliance rates improve — from 48% in 1994 to 66% in 1997. Hospital-acquired infection and MRSA transmission rates decrease.
This becomes the first reported hand hygiene campaign with sustained success and improvement over several years — a type of campaign that has since been replicated. The model for the campaign is adopted by the First Global Patient Safety Challenge to develop a hand hygiene improvement strategy for the World Health Organization.