1. Pants, Policies and Paranoia
Dr Stephanie Dancer, NHS Lanarkshire

3. Pittet D et al, Lancet 2000

4. The global pursuit of clean hands
Slide courtesy of Dr I. Gould

5. The global pursuit of clean hands
• Pittet et al publish sentinel study, ‘Effectiveness of a
hospital-wide programme to improve compliance
with hand hygiene’, Lancet 2000
• Use alcohol gel: UK National Patient Safety Agency,
2004. ‘Patient safety alert: clean hands help saves
lives’.
• WHO guidelines of hand hygiene in health care,
Geneva 2005
• ‘Why healthcare workers don’t wash their hands: a
behavioural explanation’, 2006
• ‘Five moments for hand hygiene’, WHO 2006
• Interventions to improve hand hygiene compliance
in patient care, Cochrane Review 2007
• Educational interventions for prevention of HAI,
Systematic Review 2008

6. Interventions to improve hand hygiene in the UK
Cardboard cut-outs; educational packages;
extra staff; more managers; hand-hygiene co-
ordinators; committees; audits; nice-smelling
soaps; UV detectors; antiseptic soaps, liquids
and gels; soft towels; signs; talking boxes; stick-
on gizmos; prominent hand-hygiene stations;
badges (for staff); badges (for patients); more
audits; notices; posters; e-mails; conferences;
screen savers; Matrons; labels; observers;
flyers; more audits; antiseptic containers
attached to beds; antiseptic containers in
pockets; reminder letters; feed-back; lectures;
coloured stickies; more audits; flashing signs;
cameras; violation letters; CCTV; more sinks;
floor artistry; rewards; covert audits; T-shirts;
lollipops; electronic detectors; laser beams;
spies beneath beds; sniffer dogs; psychological
Photo: BBC counciling; brain washing; torture....

8. Dept. of Health Social Services 2007;
Dept. of Health Guidelines 2007;
Scottish Government Health 2008
• Bare-below-the-elbows
• No wristwatches
• No jewellery
• No ties
• No pens or scissors in outside pockets
• No white coats
• No leaving work in uniform

9. And now?
‘Zero Tolerance’.....................
Scottish Executive: Zero tolerance to non hand hygiene
compliance, 26th January 2009
The expression ‘Zero Tolerance’ imparts both the idea of tackling low-level
hygiene misdemeanours and of doing so in a particular way, namely
through aggressive, uncompromising law enforcement
Pollard C, ‘Zero tolerance: Policing a free society’, IEA Health & Welfare Unit, 1998
But……….if there are not enough sinks, staff, gel and/or beds, is poor
hand hygiene really our fault?
Goldmann D. System failure versus personal accountability – the case for clean
hands, New Engl J Med 2006
There should be a balance between the system
and an individual’s behaviour

10. Isn’t this ‘Zero Tolerance’?
‘’Hospital worker in disciplinary case over hygiene’’, Mail, Sept. 21st, 2010

11. If there is little justification for ‘Zero Tolerance’,
then what is there for hand hygiene?
What is the evidence that cleaning hands stops patients
getting infections?
Reviewing current evidence.....
concluded that there is a lack of
rigorous evidence linking specific
hand hygiene interventions with the
prevention of HCAIs
Backman et al, Am J Infect Control 2008
Patients are still at risk of infection in today’s hospitals despite huge
investment in promoting hand hygiene….there must be other factors
important for controlling infections that erode the benefits from
improved hand hygiene
Dancer SJ, Leader J Hosp Infect 2010

12. What about bare-below-the-elbows?
149 medics were randomised into 2 groups;
One group was BBE and the other was not;
All medics had their hand washing
technique evaluated using fluorescent gel
There was no significant difference in the overall
percentage area missed after handwashing
The group wearing white coats did miss
significantly more of the wrist area
Being bare below the elbows improves wrist
washing
Do patients acquire hospital organisms from a
doctor’s unwashed wrists?
‘Bare below the elbows’ and quality of handwashing: a randomized comparison study. J Hosp Infect 2009

13. Alan Johnson
cleans his hands
during a visit to St
Mary's Hospital in
London
Photo: Telegraph, 23 Sept 2008
Looking the part………..
That’s what it’s about

14. Are there benefits in using alcohol gel?
Introducing alcohol hand antiseptic into a hospital reduced
VRE but had no effect on MRSA
Larson et al, Behav Med 2000; Lai et al 1CHE, 2006
Hand hygiene rates improved dramatically after
introducing hand gel into two ICU’s, but there were NO
changes in the rates of device-associated infection, or
infections due to multi-resistant pathogens or C.difficile
Rupp ME et al, ICHE 2008
Excessive use of hand hygiene products is not an efficient
way of reducing infections in low-prevalence wards
Herud et al, AmJIC 2008
Hand hygiene compliance and consumption of alcohol gel does
not correlate with pathogen transmission in ICU
Eckmanns et al, JHI 2006

15. Does hand hygiene compliance and consumption of alcohol
gel correlate with pathogen transmission in ICU’s?
Eckmanns et al, JHI 2006

16. Does alcohol gel aid in the
control of C.difficile?
No effect! (Boyce et al, ICHE, 2006)
Norovirus?
Probably not (Lages et al, JHI, 2008)
Acinetobacter?
Left wondering....
(Edwards et al, JMM 2007; Pittet et al, LID, 2008)
Alcohol enhances the pathogenicity of clinical CNS
(Milisaviljevic et al, AmJIC 2008)
....and vulnerable people drink it (24dash.com, 2008)

17. Have hand hygiene interventions had any effect on MRSA?
S.aureus bacteraemia, HPA 2009

18. Yes! No! Maybe...........
MRSA rates are down
BUT – these rates are based upon bacteraemias. How do we know that total
MRSA acquisitions are down? No one is counting these.
MRSA bacteraemias surely have reponded to enhanced screening, topical
clearance strategies and intravascular catheter care bundles; but not necessarily
increased hand hygiene.
What a pity meticillin-SUSCEPTIBLE S.aureus bacteraemia rates have
barely changed.
If enhanced hand hygiene is responsible for the decrease in MRSA rates, then
why have MSSA rates stayed the same, or even gone up?
What about C.difficile?
HPS Weekly Report 6/10/10; Dancer SJ, J Hosp Infect 2010; Dancer et al, ECCMID 2010;
S.aureus bacteraemia, HPA 2010; Orthopaedic SSI 2004-9, HPA 2009

19. Ceftriaxone consumption and cases and cases ofhospital over a two
Ceftriaxone consumption of C.difficile in a C.difficile in a
year period
hospital over a two year period
90 3.5
80
3
Cases C.difficile/1000pt/occ.bds
70
2.5
DDD's 1000pt/occ.bds
60
50 2
40 1.5
30
1
20
0.5
10
0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Months Dec 2007-Dec 2009
Ceftriaxone consumption No. of cases of C.difficile

20. Why isn’t hand hygiene having an effect?
Overall compliance for hand
disinfection was 22% from
nearly 600 opportunities for
hand hygiene
Kim PW et al, AmJIC 2003
Staff are too busy!
Dancer et al, AmJIC 2007; Hugonnet et al, Crit Care
Med 2007; Erasmus et al, ICHE 2010
Overcrowding & understaffing
Beggs et al, BMC Infect Dis 2008;
Clements et al, LID 2008
The effects of hand hygiene are
eroded if the environment is
heavily contaminated…..
Farr et al, LID 2001

21. People are dirty b*****s
Compliance with hand hygiene after toilet visits was
84% for ECCMID attendees, 75% for men in public
toilets and 46% for hospital staff!
Van der Vegt & Voss, JHI 2009
28% commuters have faecal bacteria
on their hands Judah et al, Epidem Infect 2010
Only 43% of mothers wash their hands after changing a
dirty nappy Curtis V et al, Soc Sci Med 2003
34% male and 56% female members of the
public wash their hands after using public toilets
Jumaa & Hately, BMJ 1999
Americans Don’t Alter Hygiene Amid Swine Flu Threat
Bradley Corp., USA Sept. 2009

22. Healthcare Workers are more concerned about protecting
themselves than protecting their patients
Scheithauer et al, J Hosp Infect in press 2010

23. Where’s the REAL risk?
Activities such as handling curtains or
patient’s notes do not register as ‘dirty’, yet
they could pose more of an infection risk
than removal of a bed pan, because staff
are more likely to clean their hands after
performing the latter.
Contamination of hospital
curtains with healthcare
associated pathogens.
Trillis et al, ICHE 2008
…beliefs about the importance of self-protection are the main
reasons for performing hand hygiene
Whitby et al, ICHE 2006; Erasmus V et al, ICHE 2009; Dancer SJ, ICHE 2010

24. ‘I wonder what’s on his hands....his white coat......his stethoscope.......’
SHOULD I REMIND HIM TO WASH HIS HANDS?
Photo courtesy of Clean Path Solutions, LLC, Nevada USA
Dancer, J Hosp Infect 2010; Burnett E, J Hosp Infect 2010

25. Bye bye social niceties
Bye bye friendly touch
Jang et al: Staff physician: ‘If … someone is upset and they’re crying
and they want human contact, you can’t say, just a second I’m going
to wash my hands.’
Jang et al, J Hosp Infect in press 2010

26. On the state of public health:
Annual report, Chief Medical Officer 2006
Dept of Health, London.
The CMO stated that hand
hygiene is a major priority and
quoted examples of poor practice
by doctors and nurses.
But overuse of NHS facilities is a
critical factor in controlling
infection – so why are increasing
bed occupancy rates, increased
turnover and lack of isolation
facilities not mentioned?
Richardson NBG. What about reducing turnover? BMJ 2007; 335: 221

27. Bed occupancy, turnover intervals and MRSA rates
Cunningham et al, Br J Nursing 2006

28. Crowded wards 'add to patient infection risks'
Overcrowding of wards and staff shortages
contribute to hospital infections. One in 10
patients admitted to hospital in Britain acquires
an infection and the threat from MRSA and
Clostridium difficile is the direct result of efforts to
reduce beds and increase efficiency.
In England, the number of hospital beds has
been cut by more than 25 per cent since 1981
but patient numbers have soared. Over 70% of
NHS trusts exceeded the Government's target
bed occupancy rate of 82%.
Clements et al, Lancet Infectious Diseases 2008

29. Microbial load in the environment....is associated
with bed occupancy rates
S.aureus & MRSA are found
on lockers, overbed tables
and beds; finding these at any
site was significantly
associated with higher aerobic
colony counts from that site
(p=0.001) as well as bed
occupancy rates
Dancer SJ et al, IJEHR 2008
‘Priority should be given to improving the
cleaning of sites around the patient's
bedside. These are the sites that are both
frequently contaminated and frequently
touched, thereby making them important
for transferring bacteria to patients.’
Peter Obee, PhD thesis, 2009

30. There is a heavy bioburden on all hand-touch sites
Microbes can survive on surfaces for months. X denotes tested surfaces
Hayden et al, SHEA 2004

31. What’s on YOUR hands??!
Even if you keep your hands clean ALL THE TIME, any benefits from
hand hygiene are eroded if there is MRSA or C.difficile on the very
next surface you touch
Bobulsky G et al, CID 2007; Farr et al, LID 2001

32. When are the hands of healthcare
workers positive for MRSA?
5% fingertips from 500 HCWs were MRSA positive;
6% after clinical contact; 7% after environmental
contact; and 4% after no specific contact.
MRSA was recovered on 3% occasions after using
alcohol rub; 6% after 4% chlorhexidine; 3% after
hand washing with soap & water; and 5% with NO
hand hygiene.
Creamer et al, JHI, 2010
What is the point in continually asking
HCWs to clean their hands, if it is
inevitable that they are going to touch
something in the environment?

33. It’s just as easy to pick up organisms after touching a patient's
environment as it is by touching the patient
MRSA and VRE in this room are picked up by attendant staff –
and also by the next patient
Boyce et al, ICHE 1997; Huang et al, Arch Intern Med 2006; Drees et al, ICHE 2008; Hayden et al, ICHE 2008

34. Date Specimen site Environment PFGE profile
24.7.06 Foot 15e§
10.8.06 Nose 15b/15z/15-71
18.8.06 *Foot 16-237/16-296
21.8.06 Groin 15h/15-133
21.8.06 Nose 15a§ Table to show the
23.8.06 Nose 15e§
23.8.06 Groin 15h/15-133 molecular relationships
26.8.06 Groin 16-237/16-296
31.8.06 Nose 15a§ between patient and
08.9.06 Nose 15d/15-74
21.9.06 *Groin 15b/15z/15-71 environmental strains of
25.9.06 Computer 15-73§
06.10.6 Patient notes 15-73§ MRSA on one surgical
11.10.06 Overbed table 15-73§
13.10.96 Throat 15a§
ward over a one year
18.10.06
07.11.06
Heel
Hoist
15b/15z/15-71
16-237/16-296
period
07.11.06 Door handle 16-237/16-296
27.11.06 Throat 15b/15z/15-71
13.2.07 Hoist 15a
13.2.07 Bedside locker 15a§
13.2.07 Desk 15e/15-121
14.2.07 *Arm 15b/15z/15-71
18.2.07 *Catheter line 15b/15z/15-71
19.2.07 Bed frame 15e/15-121
19.2.07 Overbed table 15b
21.2.07 *Throat 16-98/16-118
08.3.07 Bed frame 15a
22.6.07 Bed frame 15e/15-121
27.6.07 Hoist 15d/15-74/15-304
04.7.07 Desk 15b/15z/15-71
12.7.07 *Throat 15z/15-71/15-119
21.7.07 BP stand 15b§ Dancer et al, BMC Med 2009
23.8.07 Nose 15a

35. Dancer et al, BMC Med 2009

36. Cross-transmission audit of
surfaces, clinical equipment and
patient: Who touches what?
We undertook 40x30 minutes covert audit of
entries into a side-room on a medical ward.
Overall compliance with hand hygiene among
A room with a view clinical staff before and after entry was 25%
(38/154)
Over half (58%) of clinical staff touched the patient;
Most frequently handled equipment inside: IV drip (27%) & BP stand (13%);
outside: computer (25%), notes trolley (23%) and telephone (22%).
Monitoring the sequence of hand-touch events highlighted potential microbial
transmission pathways.
Since hand hygiene compliance is so low, should we not
target high risk sites for cleaning?
Smith et al, in preparation, 2010

37. What is the evidence for cleaning as a viable control
mechanism for hospital-acquired infections ?
We introduced one additional cleaner into
two matched wards from Monday to Friday,
with each ward receiving enhanced
cleaning for six months in a cross-over
design;
Enhanced cleaning was associated with a
33% reduction in levels of microbial
contamination at hand-touch sites;
The number of new MRSA infections
decreased from 9 to 4, despite higher bed
occupancies and MRSA colonisation
pressures (p=0.032: 95% CI 7.7%, 92.3%).
Dancer et al, BMC Med, 2009
BBC website, 2008

38. Total aerobic colony counts (ACC) from ten hand-touch
sites on two surgical count from tenstudy cleaner moved
Total aerobic colony wards; the hand-touch sites on two
matched surgical wards
from Ward A to Ward B at week 13.
140
120
100
Total ACC
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Weeks
NB. Middle 6 months of study Ward A Ward B Dancer et al, BMC Med, 2009

39. The Hand-Touch equation
=
Hand
Hand-touch site
WHY is all the emphasis on cleaning hands and not
on cleaning the things that they touch?
‘Zero tolerance’ should exclude inadequate cleaning in our hospitals

40. DYNAMIC TRANSMISSION CYCLE
OF HOSPITAL PATHOGENS
Patients
(infected and/or
colonised)
Antibiotic
Pressures
Berntsen et al,
NEJM 1960; Cheng
et al, JHI 2008
Hands Environment
(whose?) including air

41. Could patients’ hands constitute
a missing link? Banfield & Kerr, J Hosp Infect 2005
Figure from Pittet et al, Lancet Infect Dis 2006
What is the impact of systematic patients’ hands disinfection on
MRSA infection rates? Gagne et al, J Hosp Infect 2010

42. Distribution of S.aureus in general
population and nasal carriers
General Population: S.aureus nasal (+):
Wertheim et al, Lancet Infect Dis, 2005; Dancer S, Lancet Infect Dis 2008

43. The ‘Cloud Adult’ – sort of
Courtesy of the American Association for the Advancement of Science

44. Let’s screen everyone for MRSA!
Is it ethical to subject a population to mass screening, given the low
prevalence and the relatively high rate of false positive tests?
(Millar M, J Hosp Infect & BMJ 2009)
Is it ethical to screen every patient coming into hospital when we do
not routinely screen healthcare staff?
Is it sufficient to only screen the nose rather than include other sites
known to be common staphylococcal reservoirs?
How good is mupirocin nasal cream for eliminating carriage?
Is there a risk that we might encourage resistance to mupirocin?
Can the laboratories cope with the extra workload?
Do our hospitals have the infection control infrastructure to
cope with an increase in newly identified MRSA patients?
Dancer SJ, Considering the introduction of universal MRSA screening, J Hosp Infect, 2008

45. A universal, rapid MRSA admission
screening strategy did NOT reduce
nosocomial MRSA infection in a surgical
department with endemic MRSA ……
Harbarth S et al, JAMA 2008

46. S. aureus dispersal from nasal & perineal carriers
Solberg, Acta Med Scand Sppl.1965

47. Surgeons! In fact, everyone……did you know that your
choice of underwear could be an infection control risk?
It is only a matter of time before the Dept. of Health insists that we all
wear elasticated pants. Please see me afterwards for website details.
Hill et al, Effect of clothing on dispersal of S.aureus by males and females, Lancet 1974

49. Bacterial contamination of
white coats......
Stethoscopes, pens,
cuffs, ties, rings,
watches, and so on
Let’s get rid of them!

50. What’s wrong with ties?
Steinlechner et al, Microbes on ties: do they correlate with wound infection?
Ann R C Surg Engl, 2002

51. What’s wrong with wristwatches?
About three-quarters of watches from 100 staff
were colonised with skin bacteria, with retrieval
of just one pathogen (S.aureus) from one watch
only. The group concluded that wristwatches are
unlikely to be common sources of healthcare-
associated infections
A more recent study suggests that the risk of
bacterial contamination on the hands of watch
wearers originates from manipulation of the
watch, but not necessarily from the wearing of it
Bhusal et al, AmJIC 2009; Jeans et al, JHI 2009

52. What items of attire do patients perceive as
an infection risk?
Items perceived as an infection risk
80 75
Nose ring
70 62 Bracelet
60
50 49 Wrist watch
50 Engagement ring
40 37
% of 34 Earrings
31 29
patients 30 25 24 Long sleeves
20 Neck tie
10 Wedding ring
Necklace
0
Items Bow tie
Ardolino et al, J Hosp Infect, 2009

53. If we can’t wear white coats and ties, what do we
wear instead?
This?
Or this?
Shelton et al, J Hosp Infect, 2009

54. Goodbye white coats……………….

55. Cartoon from Private Eye, 2007

56. Letter, BMA News Review Sept 2008
‘.......... no-evidence knee jerk interventions such as bare-
below-the-elbows, no watches, even hand hygiene - imply
that staff, visitors and even patients themselves are
responsible for ...... hospital infections
Hospitals actually need more space, beds, isolation
rooms, nurses and cleaners - not targets, clipoards or a
culture of blame. And yes, we want laundries back on site,
with clean coats (white), uniforms and linen for everyone
who needs it, every day.
The problem is, all this costs money, and it costs a lot
more than a few bottles of alcohol gel, posters and
dictatorial fingers pointing at healthcare staff.’
Magos A et al, A cheap sound bite, BMJ 2007

57. Sunday Telegraph, November 29th 2009

58. Conclusion
There is little if no evidence for the recent policies imposed
upon healthcare staff in the name of infection control
The interventions that would really make a difference cost
a lot of money and are difficult to implement
Zero tolerance is a politician’s mandate to reassure the
electorate on hygiene behaviour in our hospitals; BUT, if
we ever get the system right, the focus will be on personal
accountability
If you are a hospital employee, then you have NO CHOICE
but to comply with these policies……..so,
Be seen to keep your hands clean

59. Acknowledgements
• ICN’s Pia Kirkpatrick and
Christina Coulombe
(for info)
• Mike Stewart and staff in the
Hairmyres microbiology lab
(for support)
• BMA (ditto)
• Miss N. Sturgeon, Scottish
Health Minister
(for good intentions)
Please note that the views expressed in this presentation will not necessarily be
representative of the views of the Hospital Infection Society nor NHS Lanarkshire

60. They didn’t wash their hands..........

62. What is Zero tolerance?
…..a politician’s mandate to reassure the electorate on hygiene
behaviour in our hospitals. Commentators and others latch on to this
term because it is seen as the latest fashionable label to prescribe the
solution to all our hygiene problems
…..a simplistic, short-term quick-fit fix, which will not, and cannot, reach
into the heart of the infection control problems in our hospitals
‘….zero tolerance is no more than one fundamental principle of several that need
to be carefully and sensitively woven together if infection control is to work well’
However, BEWARE! We need to get the system right, and when we do, the focus
will be personal accountability AND THE CHARGE WILL BE VIOLATION!
Pollard C, IEA Health & Welfare Unit 1998;
Dancer S, 2009; Goldmann D, N Engl J Med, 2006