President's Page October 2006 It's so easy— Simple hand hygiene reduces infection

by David M. Bookout, MD 2006 DCMS President

Remember the popular song that began with these words—“It’s So Easy”? The song had nothing to do with medicine, but its title should be our mantra in this era of emphasis on patient safety, medication error, and nosocomial infection. Have we forgotten what we were taught in school, or chosen to ignore what we know as right? As I reflect over my career, I have difficulty explaining our attitudinal changes.

Medical school lectures taught us the importance of having a diagnosis prior to treating or prescribing antibiotics. Overuse of antimicrobial agents fosters the spread of antimicrobial-resistant organisms. Approximately 50% of prescribed ambulatory antimicrobial drugs are prescribed for patients who have viral respiratory infections. The responsibility for this lies with both clinicians and patients. Patient demands—perceived or actual—create challenges for physicians, and too often we relent and prescribe rather than attempt to educate.

The mounting pressure for hospitals to meet “quality” standards for Medicare reimbursement has resulted in some unanticipated results. The antibiotic administration in community acquired pneumonia (CAP) is measured in a designated time from emergency room arrival. The patient arrives with shortness of breath, fever, and chest pain, and may have viral infection, angina, a pulmonary emboli, or other problems. But it might also be CAP. Appropriate studies are ordered: a chest x-ray, blood cultures, EKG. Before the tests are completed, the time to give the antibiotics arrives. If the antibiotic is not given, the quality staff, the hospital administration, and Medicare will be unhappy with you, the evaluating physician. So, give the antibiotics. What’s the harm? The harm is that the current antibiotic, which is used for sepsis in urinary tract infections, has become ineffective because of antibiotic resistance.

The overutilization of antibiotics may be leading to more resistant strains in other areas. A recent report (Ob-Gyn News, 8/1/06) told of an increasing number of community-associated methicillin resistant S. aureus (CA-MRSA) infections in New York City, and similar reports have come from Chicago and Los Angeles. Another report of CA-MRSA infection was in a body builder who had an abscess after he injected a steroid solution.

Article after article states that the real solution is not the administration of antibiotics, but is getting the medical staff—physicians and nurses—to wash their hands. According to D.P. Goldman, MD, in a New England Journal of Medicine article (7/13/06), “When a doctor or nurse can reduce the spread of antibiotic-resistant bacteria by practicing simple hand hygiene, accountability should matter. Each caregiver has the duty to perform hand hygiene perfectly every time. We cannot continue to blame the system.”

The concept of a “patient zone” must be incorporated to prevent the spread of infection. Contamination can come from wounds, but also from intact patient skin, patient gowns, bed linens, furniture, and other objects in the patient’s immediate environment.

This is not a new concept. In 1847, Ignac Semmelweis deduced that when physicians did not wash their hands consistently or well enough, they were to blame for puerperal fever, the leading cause of maternal death in that era. He mandated hand hygiene, and the death rate fell from 20% to 1%. The physicians were offended that he would suggest they were responsible for the death of these patients. Semmelweis was dismissed from his job.

This story is a good example of the obstinacy and blindness of physicians. It has been suggested that the best solution may be to give up on hand washing and to get physicians to stop touching patients.

It’s so easy.

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