Health Promoting Hands

In the history of public health there is the story of John Snow. Dr. Snow was a careful observer and analyst of a cholera epidemic in 1854 London. Before germ theory was understood, Snow was convinced that people were getting sick from a water cistern (the Broad Street pump), and removed the handle from that pump to block further contact with the contaminated water. From the perspective of London residents and even contemporary medical “experts,” the end of the epidemic was miraculous.

The dynamics of controlling a point source exposure are fairly simple, especially from the vantage of the 21st century. In contrast, many infectious disease threats are much more complex. To give a single instance, alarm has escalated in response to infectious diseases often acquired in health care facilities, and often resistant to anti-biotic treatment. An important example is methicillin-resistant staphylococcus aureas (MRSA). There are others, but MRSA is a good sentinel of this group of organisms. Each year there are about 90,000 hospital cases of MRSA with 15,000 deaths. With all infections acquired in hospitals there are about 1.7 million cases and 99,000 deaths. Tabulated together, these infections would be the 6th leading cause of death in the U.S.

Unlike Snow’s cholera outbreak, the MRSA epidemic is many times more complex. There are many things hospitals are doing to protect patients and personnel, but one of the most basic is hand hygiene. Very often these infections are transmitted by hands. Nurses and other workers are instructed to wash or sanitize their hands before and after any direct patient contact. However, hand hygiene in the hospital is like a wheel in a wheel in a wheel. First of all, in modern hospital care there is an astounding array of workers involved with each patient: often multiple physicians, numerous nurses and aids, dieticians and food service workers, allied health technicians and therapists, housekeepers, maintenance workers, volunteers, chaplains, and students in all of those fields. Often there will be many family members coming into a patient’s room as well. With the sheer number of hands and the range of understanding with respect to infectious disease transmission and risk, it is extremely difficult to get everyone to comply with what science has established as best-practice. Often staffing resources mean that nurses and aids are chronically pushed for time; frequent hand washing can add a significant time burden to their workday. Personnel don’t like to wash 100 times a day because it can take a toll on their skin. Human factors engineers are doing a better job pinpointing the placement and perfecting the design of sanitizers, sinks, soap and towel dispensers to create circumstances where hand hygiene is made easier and more convenient. Remember also that hand hygiene is a behavioral problem; no such problem is solved with information alone, but many other factors must be considered.

In light of all this complexity, it should be no surprise that the hospital workforce is not entirely compliant with hand hygiene best practice; this includes physicians. Unlike some health threats, like highway injuries which can be managed with peak risk time precautions, hospital acquired infection is a 24/7 risk. The overall threat of drug resistant infectious disease is truly a scary specter for the human family. Unless we can do a better job in managing anti-biotics, there is the real possibility that infectious diseases will be increasingly beyond our ability to control.

Now for some good news. From 2005 to 2008, hospital MRSA declined by 28%. That is great news for anyone who visits, works in, or is admitted to a hospital. It is a great victory for all the public health measures being instituted in every hospital. John Snow would be pumped.

Note: I want to thank my colleague, Dr. Ruth Carrico. Though not a source for this post, she has taught me about clinical infection control concepts.