I ALSO DISAGREE with Instruction No. 1. This step soundly advises patients to ask hospital staff to clean their hands before treatment. To be sure, the importance of hand washing cannot be overstated. But, this step’s discussion might cause the reader to conclude (erroneously) that alcohol-based hand cleaners and gels are more effective than soap and water at reducing the risk of HAIs.
A study published this January (2008) appears to belie this conclusion, having found that, while it improved hand-hygiene compliance, the use of an alcohol-based hand gel, compared to a standard hand soap lotion, did not reduce the rates of several different types of studied HAIs.9 This study’s findings are significant, because they suggest that alcohol-based hand cleaners and gels may not result in improved patient outcomes as the discussion provided along with the advice of Instruction No. 1 implies.
Alcohol-based hand cleaners and gels may not result in improved patient outcomes, compared to ordinary soap and water.
Further, Instruction No. 2—which advises patients to ask that the stethoscope’s diaphragm “be wiped with alcohol” before its use—warrants clarification. Indeed, wiping a surface with 70% (isopropyl) alcohol might reduce the risk of disease transmission. But, this outcome is a consequence of the cleaning effect of wiping, not the biocidal activity of 70% alcohol as this step’s advice intimates. The immersion of an instrument in, and not merely momentarily wiping its surfaces with, 70% (isopropyl) alcohol for up to 5 minutes may be necessary to destroy all types of viruses (e.g., the hepatitis B virus) and achieve the level of disinfection necessary to prevent HAIs.10
Immersion of an instrument in 70% (isopropyl) alcohol for up to 5 minutes may be necessary to destroy all types of viruses and achieve the level of disinfection required to prevent disease transmission.10
ALTHOUGH SEVERAL OF this checklist’s 15 steps are evidence-based, none discusses the contribution of wet surfaces, instruments, and hands to HAIs. While emphasizing the importance of hand washing, Instruction No. 1 would be more complete if it had noted that hand drying after cleaning is an important aspect of hand hygiene and contributor to the prevention of HAIs.8,11,12 Providing advice on hand hygiene, the CDC states that:
Wet hands have been know (sic) to transfer pathogens much more readily than dry hands or hands not washed at all. The residual moisture determines the level of bacterial and viral transfer following hand washing.(11)
Nor does this checklist of 15 steps advise patients to ask their doctors to dry medical instruments that are wet with water or moisture at the time of treatment. Several published studies document HAIs caused by the clinical use of wet (or improperly dried) endoscopes and other types of instruments (and surfaces). The significant contribution of endoscope drying, for example, to the abrupt termination and prevention of true (and pseudo) outbreaks of opportunistic microorganisms that thrive in moist environments—such as Pseudomonas aeruginosa—is well-documented.
Click here to read Dr. Muscarella’s article in the journal Chest about the importance of instrument drying.
Moreover, an operating room group states that: “wetness or dampness creates doubt about the sterility of (a surgical instrument) set, and it should be considered unsterile.” The reader would be hard-pressed to identify a more dubious clinical practice than the all-too-often routine introduction of wet (with rinse water) bronchoscopes, cystoscopes, ophthalmic instruments, or arthroscopes in to the lungs, bladders, eyes, or knees, respectively, of patients to treat disease.13
WHETHER PATIENTS ASKING their doctors to clean and dry their hands, as well as to use during treatment only medical instruments that are sterile (or disinfected) and dry would effect change and markedly reduce the risk of HAIs is unclear. Nevertheless, these two recommendations would seem to be no less practical, empirically-based, or important to the prevention of HAIs than several of this checklist’s 15 steps.
Therefore, this blog recommends that this 15-step checklist be amended to express concern about the blanket administration of pre-surgical antibiotics and to provide a discussion of the importance of drying and the increased risk of HAIs associated with wet hands and wet instruments.
(References to this editorial are available on request.)
Blog by: Lawrence F Muscarella, PhD posted on 1/16/2013; updated 8-22-2013.