At times when I talk with hospitals about the importance of healthcare workers performing hand hygiene I am asked:
“Yes, you can significantly improve hand hygiene compliance, but what is the business case? Does Sani nudge really prevent infections?”
Why do we still doubt the business case of improving hand hygiene compliance in 2019? Politicians are strongly enforcing that healthcare workers perform hand hygiene and hospitals spend millions of euro on soap and alcohol each year.
Why not answer the hospitals question, by telling a true horror story based in a world where no nurse washes his hands before touching a patient, where no doctor sanitizes her hands when she does her patient rounds and where no bio-analyst sanitize his hands when doing an IV. Well, this remarkable, shocking, and absolutely unrepeatable study from the 1960s sets the scene.
At a not so long time ago before neonatal units were invented, ethics committees, and when hospitals did not have hesitations on using patients for scientific research. Back then, there was a study group that had come up with a study to answer an ancient question; Can proper hand hygiene compliance of healthcare workers prevent hospital acquired infections? The study group had set up a cohort intervention study performed in a nursery for newborn babies in an American hospital. The study was set up in a seven bedded nursery for newborn babies. A baby with a strain of staphylococcus aureus were placed in the index cot, and the other six cots arranged in two rows of three, designated rows A and B. The nursing staff on the unit were required to handle the infected babies before any of the other babies. Then, nurses allocated to the A cots performed hand hygiene, whereas nurses allocated to the B cots did not perform hand hygiene at all.
What do you think happened? If you do not believe in the business case behind proper hand hygiene compliance, you must think that nothing happened and that all the babies grew up healthy and happy.
But if you believe in the business case, you know what kind of horror story this will turn into in chapter two!
Days passed by as nurses performed hand hygiene before taking care of one half of the cots while they did not perform hand hygiene before taking care of the other. One cot was always occupied by a baby from the ward with a strain of staphylococcus aureus and the nurses always took care of this baby first. Imagine all the care and attention the babies in the infected cot got. Over the 48 days of the study, 16 different infected babies went through the nursery and a total of 81 babies in cot A and B. 49 babies were admitted to the B cots and 32 where admitted to the A cots.
To the horror of the nursery the babies in the B cots started to become very ill. 92% of the 49 babies admitted to the B cots had acquired staphylococcus aureus!
53% of the 32 babies admitted to the A cots (with hand hygiene) also acquired staphylococcus aureus, but the time before they were infected was a lot longer. The babies in cot B was infected in just 35 hours compared with 133 hours for the babies in the A cots where the nurses performed hand hygiene.
These results shocked the nursery.
57 years after the the horror, hospitals around the world are still doubting the importance of hand hygiene compliance.
Scary right? The study was performed in 1962 - a long time after the days of Semmelweis and the apparent evident proof that hand hygiene significantly impacts the occurrence of hospital acquired infections.
Skeptics may try to make the case that “It’s only antibiotic susceptible aureus, and about 1/3 of humans carry that anyway.” Except that a) these are newborn babies, working out their microbiota and b) colonization with staphylococcus aureus is a risk factor for infection.
Why did around half of the babies in the A cots get infected? We do not know anything about compliance with the intervention. Hand hygiene compliance in today’s hospitals are at 20-40% so there is still plenty of room for transmission of pathogens. Perhaps the hand hygiene step was only partially effective (it was a 10 second waft with some disinfecting solution). Or perhaps, since only the nursing staff were allocated to hand hygiene or not, other staff groups like doctors explain the high transmission rate in the A cots.
This study probably shouldn’t have been done in the first place, and we certainly won’t see anything like it performed again. However, it does graphically and dramatically illustrate the importance of hand hygiene to maximize patient safety.