In this interview, we speak with Megan Amerson-Brown, PhD, MLS, CIC, a member of the CBIC Board of Directors, to delve into the importance of hand hygiene in healthcare settings. With years of experience in infection control, Megan provides critical insights into common misconceptions surrounding hand hygiene, the role of environmental factors in promoting compliance, and the impact of cultural differences on hygiene practices. She also discusses how hand hygiene plays a crucial role in preventing the spread of multidrug-resistant organisms and highlights emerging technologies that could revolutionize hygiene compliance. Additionally, we explore the lasting lessons learned from the COVID-19 pandemic and the unique challenges faced in maintaining hygiene standards in long-term care and outpatient facilities.

What are the most common misconceptions about hand hygiene in healthcare settings, and how can we address them?

Common misconceptions

• Antibacterial soap is more effective than regular soap. 
• The act of physically scrubbing your hands is the most effective way to remove soil and bacteria than antibacterial soap. There is not sufficient data to support that antimicrobial soap is more effective at removing harmful and drug-resistant bacteria than regular soap with appropriate hand washing techniques.  In addition, antibacterial soaps can disrupt and alter the normal skin flora which may promote growth of resistant bacteria. Antibacterial soap can also give a false sense of protection even if appropriate scrubbing techniques are not used.

• Hand sanitizer is better than washing hands
• Washing your hands with soap and water is the most effective way to reduce the microbial burden on your hands. Although hand sanitizer can reduce the number of microbes, they are not effective against certain microorganisms such as Clostridioides difficile and Norovirus.

• Wearing gloves removes the need for handwashing
• Hand washing is still important even when wearing gloves because the microorganisms you would normally pick up by touching things with your hand are still picked up by a gloved hand. The gloves can become contaminated and removal of the gloves can spread the bacteria to your hands. This is also why changing gloves when soiled or after certain tasks is recommended, regardless of subsequent tasks that are to be performed. 

• Hot water is better for killing germs on your hands than cold water. 
• Water that is “hot”, but at a temperature you are still able to comfortably wash your hands is not hot enough to have any growth or viability effect on the microorganisms. Hand washing should be performed at a temperature that is comfortable enough for appropriate handwashing technique. 

With the rise of antibiotic resistance, how important is proper hand hygiene in preventing the spread of multidrug-resistant organisms (MDROs)?

Proper technique and adequate hand washing has been estimated to reduce healthcare associated infections by 50%. Preventing infections is key to reducing antimicrobial usage that can lead to antimicrobial resistance. The less infections we see, the less antimicrobials get used which decreases the selective pressure on microbes that leads to the development of antimicrobial resistance.

What role does the environment (e.g., the presence of sinks or hand sanitizer dispensers) play in the compliance of healthcare workers with hand hygiene protocols?

Placement of hand washing sinks and hand sanitizer dispensers encourages healthcare workers to wash their hands by removing barriers that will otherwise prevent them from doing so in a timely manner if soiled hands occur or as part of routine hand hygiene. Placing handwashing facilities in strategic places allows for hygiene to have minimal impact on workflow. 

How do you recommend integrating hand hygiene education into ongoing healthcare staff training to ensure lasting behavioral changes?

Train the trainer programs are highly effective. 

Interactive continuing education courses offered through the hospital educational compliance systems for annual review and quiz also have good outcomes. 

Infection Prevention rounding and in the moment coaching can help correct bad habits and creeping trends. 

Can you share insights on how cultural differences in healthcare environments affect hand hygiene practices and compliance?

Some examples of how cultural differences in healthcare environments affect hand hygiene practice and compliance include areas such as 

-Negative perception of alcohol and alcohol-based medicinal agents. Many hand sanitizers are alcohol based. If these products are employed certain religions and ethnicity groups might be reluctant to use them. 

It is a common hand washing practice in some cultures to use a multi use bowl of water to wash the hands instead of running water over the hands. Multi use bowls of water risk contaminating or re-contaminating hands and passing bacteria to other persons who share the same water bowl.  

In areas with low water resources and routine drought that affects water use. Some might find it difficult to rationalize using soap and water for routine hand hygiene practice. Hand sanitizers can improve hand hygiene compliance in such areas without impacting water usage and rations. 

In overcrowded healthcare facilities or overcrowded workspaces appropriate hand hygiene can be difficult. Similar to the effective placement of hand washing and hand sanitizer dispensers having a positive impact on hand hygiene compliance rates, in areas of overcrowding and/or limited resources getting to or accessing a hand sanitizer or a hand washing sink can be difficult and therefore healthcare workers are less likely to make it part of their routine workflow.  

What innovations or technologies are emerging in hand hygiene that could potentially improve compliance and outcomes?

New developments in innovations and technologies to improve hand hygiene include:

-Electronic monitoring systems that can monitor hand hygiene in real time and provide insight into trends and habits. These systems can also send reminders to wash hands at certain steps in the healthcare workers workflow. 

-Video cameras are used to record hand hygiene compliance in high impact areas of healthcare facilities such as intensive care units. The video can be reviewed by auditors to assess hand hygiene compliance and give timely feedback to personnel. 

-Sensing technologies are still in development, however they are not able to provide a hand hygiene monitoring system that often employs a wearable device that indicates whether hand hygiene status is good and reminds users to perform hand hygiene during critical moments of care. These systems create ownership of hand hygiene among healthcare workers. 

-AI based systems with sensors and computer vision to determine if healthcare workers are using hand washing systems. 

-New Hand hygiene systems are designed to eliminate the need to touch a device with your hands to wash your hands.

- Hand Hygiene data dashboards provide real-time data that can be stratified by different metrics. 

-Educational technologies that keep healthcare staff engaged and hand hygiene at the forefront of their mind. Some of these strategies include electronic games, virtual reality, educational videos and use tablet and smartphone devices. 

How has the COVID-19 pandemic impacted hand hygiene practices, both in healthcare and in the general public, and what lessons should we carry forward in 2024?

I would hope that the COVID-19 pandemic made the general public more aware of how germs are spread in the environment. Hopefully this had a positive impact on the general public’s practice of hand hygiene, however I have yet to see data that confirmed an improvement in practice or understanding. 

In healthcare facilities hand hygiene was brought to the forefront when there were limited supplies available. While hand sanitizer was in limited supply in certain regions, handwashing sinks were not.  The pandemic provided an opportunity to reinforce that handwashing or hand sanitizer could be used when hand hygiene was necessary.  

What are the biggest challenges to maintaining high hand hygiene standards in long-term care or outpatient facilities compared to hospital settings?

Both long-term care facilities and outpatient facilities have issues with 3 areas: compliance, education and oversight. Often, these facilities do not have infection preventionists to assist in education and keeping track of hand hygiene compliance. In some cases, these facilities will only employ one infection preventionist and the issue of hand hygiene can often be drowned out by other onsite issues. Heavy workloads, poorly designed facilities and budgetary constraints of such facilities can also contribute to poor hand hygiene compliance rates.