HAND WASHING

Physicians are one of the groups of caregivers least compliant with long-established guidelines for hand washing. A steady trickle of medical news items attests to the large body of clinical research documenting poor hand washing habits of most physicians and other caregivers 1, 2, 3.

Handwashing when moving from one patient to another is simply not a regular routine of many health-care workers 4, 5, 6. Whereas 69% of registered nurses washed their hands after handling the patient, medical residents at 41% were nearly as noncompliant as radiographers, the group least likely to wash 7.

Practice Point

Noncompliance with guidelines for prevention of cross-infection is the current medical community standard

Postoperative and Intensive Care Unit infection are major sources of morbidity and mortality. Caregiver's hands probably transmit most crossinfections. Bacteria that are capable of causing serious infection abound in hospitals, especially in Intensive Care Units. Such germs are often transferred to patients on the hands of care-givers 8.

However, the proportion of hospital infections transmitted by other mechanisms - infection with the patient's own germs 9, through the air or by inanimate objects 10 and by contaminated surgical gloves 11 - is uncertain.

Practice Point

On balance of probability, noncompliance is the cause of the majority of nosocomial infections

Compliance with existing guidelines about hand washing and surgical gloves would probably prevent the majority of nosocomial infections. The solution is simple: adequate hand washing effectively removes transient bacteria from the hands 12.

Guidelines for preventing the nosocomial (hospital) transmission of bacteria and viruses have been in place for years 13. The mainstay is, not surprisingly, hand-washing between patients. The usual practice prescribed in Intensive Care Units is hand washing with an antiseptic agent, followed by the donning of boxed, nonsterile gloves 14.

Practice Point

Implementation of sustained strategies to increase compliance results in dramatic reductions in Intensive Care Unit infection rates

The activities of a nosocomial prevention team, and infection-control programmes involving regular team meetings, have been shown to significantly reduce endemic rates of nosocomial ventilator-associated pneumonia 15. Insistence on the use of gloves by respiratory therapists and other staff has been reported to interrupt nosocomial outbreaks of predominantly respiratory infections 16, 17, 18.

However, heightened scrutiny, educational and motivational efforts have been shown7 to have only limited effects.

Recognition of the problem of noncompliance with handwashing guidelines is even inherent in the wording of the Guideline for Isolation Precaution in Hospitals of the Centers for Disease Control (CDC) 19, which advocates gloves as a "practical means of preventing transient hand colonization and spread of some infections."

Practice Point

Proving that unacceptable community hand washing standards caused severe injury or death will be a formidable task

Proving negligent causation of hospital-acquired infection is nevertheless impossible in most cases. It is often a daunting task contemporaneously to collect enough evidence that noncompliance with handwashing was a necessary and sufficient cause of a particular nosocomial infection.

Proving specific causation months or years later is usually impossible, absent rare good fortune. Even in instances when an infection is caused by a single species of bacterial germ whose antibiotic-resistance profile is clearly of hospital-origin, the complexity of the possible modes of acquisition by the client is too great to prove "balance of probability".

As previously noted , only occasionally can the source of a germ be pinpointed, or a minor epidemic be shown to involve only victims who have had a specific intervention such as a contaminated surgical instrument.

Further, as the community standard is noncompliance with handwashing guidelines, the negligent acts would have to generate sufficient quantum of damages to justify appealing to the highest court that the community standard is unacceptable.

Referenced Articles
Post Operative Infection, Medical Malpractice News, Volume 2, Issue 9

Copyright 2009 Electronic Handbook of Legal Medicine