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Hands
on: a critical look at infection control
by Jane Ellwood
Our hands are the source of many infections. To ourselves and other healthy adults, the bacteria that is carried on our hands does not pose a problem, but to anyone whose immune system is compromised, the result can be overwhelming infection - and sometimes death.
The unwelcome facts are that most routes of contamination are usually passed on from faecal matter to the hands and toilet seats or bed pans, then passed onto flush levers, taps, soap bars and towels, then onwards towards door handles and, unfortunately but inevitably, to everyone else who works in that particular environment. So quite unwittingly, a visiting therapist offering massages to several clients in a communal home or ward can be a major risk for spreading infection, particularly when clients are frail and less able to fight illness.
Pre-registration nursing courses now have practical hand washing tests where washing techniques are tested using dye on the hands. Indeed, nursing journals have long since realised the importance of good hand hygiene as a major factor in preventing the spread of illness in the care environment. However, next time you have the misfortune to be an inpatient in hospital, observe the ward round - it will be very unlikely that the Consultant or Junior Doctors observe such a vital practice. Should you also have the misfortune to require a bedpan, wait to see if you are offered a clean wipe for your hands afterwards? As a nurse, patient and visitor in hospitals, I have yet to see the consistent practice of such a necessary act.
While a prerequisite for many health and beauty courses is to pass a module on health and safety in the workplace, emphasis on hand washing is usually up to the individual tutor. Effective hand washing is an essential module in food hygiene courses but not many therapists have the opportunity or inclination to study this, as unlike first aid, it would not have relevance to our continuing professional development. Yet how many of us have been shown how to wash our hands properly? - I expect (recently qualified nurses apart) not many; and how many of us have had to use our first aid knowledge during a consultation or treatment? - Again, I expect not many; yet how many of us have inadvertently cross infected clients with the bacteria carried on our hands? How do we know how many infections we have unwittingly passed on to our clients due to poor basic hand washing techniques? And are we aware that hand-transmitted diseases are responsible for 5000 deaths every year in the UK? (Plowman et al. 1999). Perhaps aromatherapy training should also focus on infection control and its relevance to our clients, as the evidence suggests that clients are at far greater risk of contracting injury from the microbes on our hands than injury due to a therapists inadequate first aid skills.
Hand to hand contact is the main mode of transmission for infections such as MRSA and Clostridium (Stone 1998), it is also responsible for spreading diseases such as Salmonella, E-coli, and Hepatitis A, which in the frail elderly and with people who have compromised immunity can result in death. So what may be an innocent small infection to you and your family can be a major killer passed on to the bodies of our clients. It has already been proved that after education and eliminating bad practices, good hand washing techniques introduced in to the hospital environment can reduce instances of acquired infection by up to 50 percent (Larson et al. 1995) - these studies were carried out on nurses who supposedly should have known how to perform the simple task of washing their hands effectively. However, it took considerable re-education and training to get more effective measures adopted, a facility that the ordinary Aromatherapists does not have at present.
Aromatherapists working in Care homes are working in a very similar environment to a hospital with residents and staff living in close proximity to each other. Washing and toilet facilities are usually shared, with staff having to perform intimate care tasks involving hygiene and body fluids as well as general cleaning and domestic duties. Residents that try to remain independent in their toileting do find it difficult to practice good personal hygiene if mobility is compromised, making their hands, fingernails and clothes a major source of bacteria to be spread from client to staff and therapist. This is why it is so important for the therapist to practice effective hand washing techniques before and after each treatment so not to contribute to the cycle of contamination and illness. Germs are not only present on the surface of the skin, but also under the fingernails, under nail varnish and of course, on rings, watches, cuffs, tunics and sleeves. Klebsiella (causing respiratory and urinary infections) can live on hands and man-made objects for over two hours (Casewell et al. 1977), which means that by the time a busy care assistant or home manager gets to wash their hands, they have already spread the bacteria over everything they have come into contact with, including doors, utensils, equipment, residents, yourself, pens, coins and visitors.
Missing the point
While we may all think that we wash our hands well, three out of five in my
nurse training group failed the hand washing practical on the first attempt. The
main areas that tended to get missed were the thumb and the pads of the
fingerprint area. Another areas commonly missed are the wrists and knuckles
(Shiells M - no date).
It helps to develop a methodical routine to carefully pay attention to all areas of the hands and wrists. The fingers need to be washed individually, particularly the folds and skin in-between.
Don't brush
Nailbrushes are now considered unhygienic as they hold and help to cultivate
micro-organisms between the bristles. The recommended method for effectively
cleaning the nails is to keep them short, rub the finger ends into the palm of
the opposite hand with plenty of soap in small circular movements. Holding the
hands under running water during and afterwards rinses the bacteria and debris
away but remember that the taps may also be a major source of
contamination.
What should we use?
Massage is not considered an invasive procedure therefore using ordinary soap to
wash our hands is perfectly acceptable. While soap does not kill or restrict
bacterial growth, it assists in removing the bacteria through rubbing and
running water (Ehrenkrantz 1992). However, liquid soap is better than bar soap,
as bar soap can hold the residue of waste matter and bacteria from the previous
user. Ideally we should be taking our own pump soap dispenser with paper towels
or a clean towel for our own personal use just in case the facilities we
encounter are not up to our own high standards.
Washing and drying
Smith-Temple (1994) recommends washing the hands for 1 - 2 minutes to be
effective. Not only is a good hand washing technique vital, but also we need a
hygienic way of drying our hands. It is pointless taking time to wash properly
if we use the same towel that everyone else has been using with little idea of
how long it has been hanging there. Paper towels have been proved to be the best
way to dry hands because they are slightly abrasive and can rub away even more
bacteria after washing. Hot air dryers are the worst offenders in spreading
bacteria with one famous study showing a 500 percent increase of bacteria found
on the hands after hot air drying as opposed to the same hands immediately after
washing; a 42 percent reduction in bacteria after drying with a paper towel; and
a 10 percent reduction after using a cotton towel (Redway et al. 1994). The
problem with hot air dryers is that they draw in air from the immediate toilet
environment in order to blow it out again in a more concentrated form. The
filters within the mechanism act as a major source for staphylococci and
Micrococci, Escherichia coli and other skin and gut bacteria - the bacteria are
then blown directly onto the hands, clothes, face and hair. The nozzles and
buttons are also a major source of bacteria as is every other touchable object
in a public washing and toileting facility.
So now we are all suitably paranoid, let us hope that we can play our part in infection control by exercising a good example to those around us. We can protect our clients from illness not only through the appropriate selection of essential oils, but also by sound working practices. I throw the gauntlet to those who plan and approve our professional development courses to help raise the awareness of effective infection control through good hygiene and hand washing techniques, and hope that we can all show our colleagues in medicine the way forwards towards good practice.
Now please wash your hands .....
© Jane Ellwood June 2002
References
Casewell M, Phillips I (1977) Hands as a route of transmission for Klebsiella species. British Medical Journal 2: 1315-7
Ehrenkrantz N J (1992) Bland soap handwash or hand antisepsis? The pressing need for clarity. Infection Control and Hospital Epidemiology 13(5): 299-301
Larson E, Kretzer E K (1995) Compliance with handwashing and barrier precautions. Journal of Hospital Infection (Supplement) 30 : 88-106
Plowman R, Graves N, Griffin M, Roberts J A, Swan A V, Cookson B D, Taylor L (1999) Socio-economic Burden of Hospital Acquired Infection. Department of Health: Public Health Laboratory Service
Redway K, Knights B, Bozoky Z, Theobald A, Hardcastle S (1994) Hand drying: a study of bacterial types associated with different hand drying methods and with hot air dryers. Applied Ecology research Group. University of Westminster: London W1M 8JS
Shiells M (no date) Hand Washing Is the Corner Stone Of Infection Control at http://www.yeoman.org.uk/html/handwash.htm
Smith-Temple J, Johnson J J (1994) Nurses' Guide to Clinical Procedures (Second Edition) Philadelphia: J. B. Lippincott Company
Stone S P (1998) The effect of an enhanced infection-control policy on the incidence of Clostridium difficile infection and methicillin-resistant Staphylococcus aureus colonisation in acute elderly medical patients. Age and Ageing 27: 561-568