While handwashing compliance among healthcare workers (HCWs) and allied staff remains notoriously low in numerous hospitals, perhaps it’s time to realize that their behavior as “civilians” when not on the job may have a lot to do with it. Recent surveys indicate that an alarming number of people don’t wash their hands after using a public restroom. In a recent observational study sponsored by the American Society for Microbiology (ASM) and the Soap and Detergent Association (SDA), 77 percent of men and women washed their hands in public restrooms, a 6 percent decline from a similar study conducted in 2005. Yet, in a separate telephone survey, 92 percent of adults said they wash their hands in public restrooms. Americans’ self-reported hygiene behavior in 2007 remains consistent with what past surveys show; among 1,001 men and women interviewed via telephone in 2007, 92 percent say they always wash their hands after using a public restroom and 86 percent say they do likewise after using the bathroom in the home. In 2005, those figures were 91 percent and 83 percent, respectively.
A recent survey conducted as part of ASM’s Clean Hands Campaign revealed that although 95 percent of men and women claim that they wash after using a public toilet, observations made by researchers discovered that only 67 percent actually do. And a survey conducted by Impulse Research Corporation found that 30 percent of Americans use restrooms away from home only when absolutely necessary. The same survey discovered that among people who do use public restrooms, nearly 66 percent use a variety of maneuvers to avoid touching anything, including using their feet to flush toilets, their elbows to open doors, and paper towels to turn off faucets and open handled doors on their way out.
In a healthcare environment, contaminated environmental surfaces are often the vectors for multidrug-resistant organisms — especially those in the washroom. Kelly observes, “Surfaces such as toilets, sinks, faucets and flushing handles, door handles, stall doors and paper towel dispensers all can pick up bacterium from unwashed hands, passing it along to the next user … studies have shown that even healthcare workers aren’t always able to wash their hands as often or as effectively as necessary to prevent cross-contamination. In fact, the Institute for Healthcare Improvement has indicated that compliance by healthcare workers with recommended hand-hygiene procedures has remained unacceptable, with compliance rates generally below 50 percent of hand-hygiene opportunities.”
Kelly continues, “Hospital staff can’t be expected to guard washrooms against those who use the toilet, neglect to wash their hands and then go on to touch other public surfaces, such as restroom door handles, before heading back to the hospital operating rooms or other patient areas. For this reason, even the most careful hand-washers are still at risk for contamination simply by touching a door handle used by someone who didn’t wash. For many hospitals, creating a touchless environment has boosted the level of staff comfort concerning the washroom, in many cases allowing them to use the facilities without touching even one surface from the time the enter the washroom to the time they exit. These include: auto-on and auto-off faucets; automatic, self-flushing toilets and urinals; auto-on and auto-off soap dispensers; automatic paper towel dispensers; and toilet seat covers activated by the touch of a button.”
“Touchless technology is a good idea, because hard surfaces are significant transfer points for bacteria and viruses,” says Charles Gerba, PhD, a microbiologist at the University of Arizona, Tucson. “Much of what people put down on a surface can be picked up by the next person who comes along, and in an age where people share more spaces and surfaces than ever before, touchless technology can help prevent cross-contamination.”
It is intuitive to think that the less a potentially contaminated surface is touched, the better, so the advent of automated sink fixtures as well as soap and towel dispensers has been heralded as an important way to reduce the opportunities for cross contamination and hand carriage of pathogenic micoorganisms. But how many clinicians consider the role that handwashing stations play in opportunities for cross-contamination?
As experts debate the role inanimate objects play in the transmission of infectious agents, few would doubt that the contamination of environmental surfaces such as handwashing sinks is a major issue. “Clearly inanimate surfaces play a role, particularly with organisms such as vancomycin-resistant Enterococcus (VRE) and Clostridium difficile,” says Columbia University’s Elaine Larson, RN, PhD, FAAN, CIC. “But it seems pretty clear that direct contact (i.e., person-to-person touching) remains the most important mode of cross transmission. Nevertheless, housekeeping and environmental cleaning seem to have taken too much of a back seat and we need to re-emphasize the great importance of keeping the healthcare setting (as well as the people) free of a large microbial bioload.”
Various studies have demonstrated infections stemming from faucet aerators, splash from sink drains and handwashing machines. In a paper underwritten in part by Georgia-Pacific, a team of researchers determined the organic, microbial and staphylococcal load on contact surfaces (faucet handles, soap dispensers and paper-towel dispensers) in four British hospitals that could be touched during handwashing, and to evaluate hand-mediated cross-infection. Manual faucet handles had a higher mean ATP level than manual soap or paper-towel dispensers, yet the latter were shown to present some presence of bacterial contamination. The study showed that contamination of hand-contact surfaces could act as a reservoir for microorganisms and could contribute to hand contamination before or after handwashing. In addition, the sink environment and its organic matter could serve as a breeding ground for potential pathogens.
A number of studies confirm that paper-towel dispensers also can be implicated in the transmission of MDROs. Researchers from the United Kingdom and the United States studied the transfer and cross-contamination potential between hands, towels, and dispenser exits if one or more is contaminated using bacteria representative of the skin’s flora. They write, “Hand drying is the critical last stage of the handwashing process and needs to be implemented in a way that reduces, rather than increases, the risk of cross-contamination. This requires that the drying is effective and that contamination of hands does not take place. However, concerns are now starting to be expressed about the dispensing of handwashing materials and the functionality of dispensing systems.”
The three methods frequently used for hand drying are hot air dryers, cloth towels, and paper towels. Whereas paper towels are recognized as the most hygienic method of hand drying, paper towels, and dispensing mechanisms (levers and mount location) have been identified as potential sources of contamination, especially for paper towels hanging in sink splash zones, according to the researchers.
The researchers used a generic wall-mounted paper-towel dispenser and a variety of different paper towels. Volunteers with either clean or contaminated hands were asked to remove, using a range of protocols, towels from dispensers which were either clean or contaminated. Previously clean surfaces were then microbiologically tested. The investigators found that recoverable bacterial transfer rates from a contaminated hand to clean dispenser exits ranged from 0.01 percent to 0.64 percent, depending on the bacteria used with an even higher transfer rate for clean towels. The reverse transfer, from contaminated exits to clean hands, was between 12.4 percent and 13.1 percent. The results indicate that zig-zag transfer of bacteria between paper-towel dispensers and hands can take place if either one is contaminated, and should be considered in the design, construction, and use of paper-towel dispensers.
The investigators write, “This study has shown that even ‘manual pull’ disposable folded towels and towel dispensers that are considered ‘hands free’ or touchless can become contaminated if the surfaces at the dispenser exit are touched. This usually occurs when the paper towel is not cleanly delivered to a user, and this varies considerably depending on the compatibility of paper towel and dispenser combination. The total number of bacteria isolated from the dispenser exits after freeing a jammed towel with a contaminated hand was relatively low but should be viewed within the context of the number of times per day this activity may need to be carried out. It is also important to note that in some cases, although the minimum infective dose can be variable, only small numbers of pathogens, especially for intestinal disease, may be required to cause illness. A number of these pathogens are known to cause outbreaks in hospitals, therefore, even the low estimates obtained in the present study still allowed for sufficient bacteria to be transferred for them to exceed the minimum infective dose for a number of human pathogens. This was particularly true of the numbers transferred from wet, contaminated hands to dry towels remaining in the dispenser. The type of contamination demonstrated in this study, coupled with the survival potential of some pathogens causing hospital acquired infections, could also assist in the spread of organisms within the hospital environment. There was an even greater transfer of both the resident and transient bacteria to the towels pulled or remaining within the dispenser. Paper towels with damp patches or spots may, in addition to being aesthetically unappealing, present an infection risk.”