Superbug solution is in our own hands

Sunday Star Times

SCRUBBING UP: Scrubbing up before surgery, but experts say healthcare workers should be washing their hands up to 20 times an hour.

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This is a common story – it may have happened to you.

You go to hospital to get something fixed or stitched or removed. The operation is a success, but along the way you pick up a superbug that infects your wounds and leaves you seriously ill. You pull through with the help of bed-rest and some serious drugs, and feel a bit aggrieved.

But then you shrug and accept that that's just the way things go these days. Everyone knows we've been overusing antibiotics for decades; we've bred bacteria that refuse to lie down even when doused in antibiotics, and now we're reaping the whirlwind.

But is that the full story?

Yes, antibiotic resistance is on the rise, but what if you were to learn that the slow-healing wounds and days off work could have been avoided if the staff who'd treated you had simply taken the time to wash their hands more often. Because chances are, that's the truth of the matter.

Around the country, 5-10% of patients admitted to hospital will develop new infections. Cases of MRSA (methicillin-resistant Staphylococcus aureus) have rocketed in the past 20 years, with more than 9000 cases last year. The bacteria causes skin abscesses, wound infections and pneumonia.

Worst-affected regions are Hawke's Bay, Northland and Auckland. In the nine months to April, Auckland's Waitemata health region had five bug-linked deaths.

ESBL – extended spectrum beta lactamase-producing bacteria – is a class of antibiotic resistant bugs. Before 1999 it was almost unheard of in New Zealand. Last year there were 5000 cases, with Auckland and Hawke's Bay worst affected.

Incredibly, a century-and-a-half after doctors first discovered that germs on their hands could transfer disease from one patient to another, and that thorough handwashing largely addressed the problem, healthcare workers the world over are being told that solving the large and growing problem of hospital-acquired infections is back in their hands – literally.

SALLY ROBERTS is clinical head of microbiology at Auckland City Hospital and a clinical adviser for infection control. She has some frightening facts at her fingertips.

In a recent Australian study, hospital workers were observed washing their hands on just 21% of the occasions they should have and Roberts says New Zealand's figures would be similar. And unwashed hands ferry dangerous bugs from patient to patient.

Why would doctors and nurses take such risks with patients' health? There are many reasons, says Roberts, and it's not just about laziness.

There are so many occasions when hand hygiene is called for: before and after touching a patient, before an aseptic procedure, after exposure to body fluids and – here's the tedious one – even after touching a patient's clothes or bedside furniture. In intensive care, where there are drips and drains and catheters all over the place, this might mean washing hands 20 times in an hour.

In the words of one overworked young Auckland doctor, who asked not to be named, hand-washing "takes time. It's only a minute, but often you don't have a minute".

He admits it's not pleasant knowing some patients leave your care sicker than when they arrived. A couple of years ago, when still a student, he was working at North Shore Hospital, which has long been battling the ESBL superbug.

"Because we had no beds, we had to put patients into an ESBL room. They didn't have EBSL when they arrived but they sure as hell had it by the time they left. That was pretty shocking to me." Protocols there have since been tightened on room-sharing.

"There are many excuses healthcare workers come up with for skipping hand hygiene," says Roberts. They're busy. Constant handwashing irritates the skin. Some workers think changing gloves will be adequate (it isn't, because microbes can penetrate the micro-holes). Or they simply don't accept they have a role in transmitting infection.

Which is where they're plain wrong.

The Health Ministry estimated in 2003 that hospital-acquired infections suck $140 million from the annual health budget. One of the big bogeymen is MRSA, which causes lethal blood infections. And a report published last month in the Medical Journal of Australia showed that up to 60% of MRSA bloodstream infections can be laid at the door of inadequate hand-washing. This is life and death stuff.

It's data like this that is driving health boards to throw their weight behind a national hand hygiene initiative, backed by the World Health Organisation, to push handwashing up the healthcare agenda.

This is great news, says Roberts – who is on the initiative's steering committee – because handwashing isn't sexy, and is easily overlooked when budgets are being set.

"On TV it's all gowns half off, running around with stethoscopes flying in the breeze; I've never seen anyone in ER or Shortland St doing hand hygiene."

The initiative – funded mainly from existing budgets – is just rolling out, but already DHBs are sending handwashing spies (or observers, as they are diplomatically called) into hospitals.

Armed with a Palm Pilot, an observer lingers in a ward for 20 minutes or so, observes 200-350 "moments" at which hand hygiene is called for, and records a "tick" if the handwashing occurs or a "cross" if it doesn't. They also note the job title of the staff member.

That data sets the baseline which the hospital will then be encouraged to beat through education, retraining, and rejigging of facilities to make handwashing more convenient.

Research shows compliance rates improve dramatically if there are alcohol-gel dispensers installed all over the place. Soliciting suggestions from staff on how to improve compliance has also been shown to be effective.

A few months later, observers will return to see if workers have sharpened up their act. In Australia, 20% compliance jumped as high as 60% or better.

"You'll never get 100%," says Roberts. Even with good intentions, changing behaviour takes time.

Just think of how long it took to get everyone to wear seatbelts. Think about how so many of us text and drive.

"Anyone with half a brain would realise that's dangerous, and yet we do it..."

www.handhygiene.org.nz