From hospitals to households, we can all be better at remembering to wash our hands



F. Cary Snyder/Unsplash, CC BY

Debbi Long, RMIT University

While Australia gradually opens up from COVID-19 lockdown, Victoria is still struggling to contain the outbreak. The Black Lives Matter protest in Melbourne on June 6, which attracted thousands of face-masked and hand-sanitised protesters, did not prove to be the public health nightmare many commentators (particularly politically conservative ones) had predicted. But Melbourne is nevertheless contending with a worrying spike in case numbers arising from infection clusters around staff working in quarantine sites and extended family gatherings.

From the beginning of the COVID-19 pandemic, we were told two behaviours were crucial to keeping us safe: social distancing and handwashing. The coronavirus crisis has brought the mundane act of washing our hands into public discussion, and the internet is now awash (ahem) with advice, from the practical to the surreal.

Judi Dench on hand with some helpful, if mildly unsettling, advice.

If there’s one place where you would expect hand cleanliness to be beyond reproach, it’s hospitals. But this isn’t necessarily the case.

Surprisingly, hand hygiene is a vexing issue in hospitals all over the world. Repeated studies have shown it is common for hospital staff to follow hand hygiene protocols less than 50% of the time. This is as true in Australia and New Zealand-Aotearoa as it is globally. As any infection control nurse will tell you, specialist doctors are often among the worst offenders.

Who teaches hospital staff how to handwash?

Like most Western-style hospitals, all Australian hospitals have infection control experts, typically nurses, whose job is to educate, advise and monitor compliance on infection control protocols among hospital workers. This is lifesaving work, because hospitals are prime breeding grounds for deadly antibiotic-resistant bacterial strains.




Read more:
Washing our hands of responsibility for hospital infections


The main line of defence in hospitals against these potentially fatal infections is prevention, hence the strict protocols around hand hygiene, and widespread use of gloves, robes, masks and safety googles.

Proper hospital hand hygiene involves using gloves, hand sanitiser, and frequent handwashing. Protocols dictate that gloves should be used in situations where health workers might expect to come into contact with blood, bodily fluids or other contaminants. Staff should wash or sanitise their hands before and after every patient contact, and in all situations where there has been contact with potentially contaminated material.

Infection control nurses undertake routine hand hygiene audits, and hospital staff can be disciplined if they fail to comply with the protocols.

Three types of handwashers

What makes hospital staff more or less likely to comply? It turns out there are different categories of handwasher, and therefore different ways to help people remember to do it.

While working on a project looking at communication in a multidisciplinary hospital team, infection control education became one of the areas of interest. Part of the study focused on the hand hygiene habits of hospital staff in a ward with particularly high infection risks.

Based on observations, interviews and informal conversations, we discovered nursing staff tended to fall into one of three broad categories: “hero healthworkers”, “family members”, and those who were “working for the whitegoods”.

Overall, most health-care workers practised good hand hygiene most of the time. But when there was time pressure — such as during short-staffed shifts, or when multiple patients were in particular need at the same time — nearly everyone had moments of non-compliance. But, fascinatingly, there were patterns to this non-compliance.


Kelly Sikkema/Unsplash, CC BY

No matter how busy things were, “hero healthworkers” always practised hand hygiene before approaching a patient’s bed. But if time was short, sometimes they did not wash or sanitise their hands on leaving the patient. Nurses (and doctors) who exhibited this behaviour tended to make comments suggesting they valued patients’ health above their own.

“Family members” always practised good hand hygiene when leaving a patient, but sometimes missed out on washing or sanitising before interacting with a new one. In each case, these staff members had vulnerable people in their household – mostly young children, and in a couple of cases older relatives. Interviews and informal discussions revealed deep concern around infection risks and “taking something home”.

The third group was mostly meticulous in their practice when observed by a superior, but much less conscientious when only peers were around. Nurses who fitted this pattern tended to be disparaged by their colleagues as “working for the whitegoods” – treating nursing less as a professional vocation and more as “just” a job to earn money.

These patterns were observed — sometimes with minor variations — in more than a dozen wards over three different hospital sites during subsequent research projects.

How to improve things

None of these behaviours appear to have been conscious, even among the least conscientious “whitegoods” group. Many staff recognised their own behaviour patterns when they were pointed out, but said they had not been explicitly aware of them.

Identifying these characteristic behaviour patterns allowed the infection control educator to target education efforts more effectively. “Hero healthworkers” were educated on the risks to other staff by potentially transmitting infection to work surfaces and other places in the hospital by not handwashing after seeing a patient. “Family members” were reminded of the risks to patients of transmitting infections in the opposite direction. And those who only complied when being directly supervised were counselled on the need to have high standards at all times.

This shift in education strategy was employed along with a number of other infection control interventions, resulting in a significant reduction in multidrug-resistant infections.




Read more:
How clean is your hospital room? To reduce the spread of infections, it could probably be cleaner


One insight we can take from this for our day-to-day realities in the middle of COVID-19 is to be reflective about our own handwashing practices. When are we conscientious, and when do we let our standards slip? Is there a pattern in our own behaviours that we can identify, and what are the subconscious beliefs driving those practices? Can we use that knowledge to change our behaviours?

The simple act of handwashing is perhaps more complex than we realise. But it is one of the things that will determine how well we fare in the current pandemic.The Conversation

Debbi Long, Senior Research Fellow, RMIT University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

My skin’s dry with all this hand washing. What can I do?



Irina Ba/Unsplash

Celestine Wong, Monash Health and Rosemary Nixon, University of Melbourne

Washing your hands is one of the crucial ways we can all help limit the spread of COVID-19.

Regularly and thoroughly washing your hands with soap and water for at least 20 seconds, or using an alcohol-based hand sanitiser, are key steps to reducing the risk.

But with all this hand washing, it’s easy to get dry skin or for existing skin conditions to flare up.




Read more:
Yes, washing our hands really can help curb the spread of coronavirus


What’s happening to our skin?

The top layer of our skin (the stratum corneum) is our skin’s key protective layer. But frequent hand washing with repetitive exposure to water, soap and skin cleansers will disrupt this layer.

Over time, this leads to dry skin, further disruption of the skin barrier and inflammation.

This eventually results in hand dermatitis, or more specifically, irritant contact dermatitis.

Who’s more likely to have problems?

Irritant contact dermatitis is more common in people who perform “wet work” as they wash and dry their hands many times a day.

They include health-care workers (doctors, nurses, personal care assistants), hairdressers, food handlers, kitchen staff and cleaners. They may also be exposed to irritating skin cleansers and detergents.

But now handwashing is becoming more frequent during the COVID-19 pandemic, there may be more affected people outside these occupations.

Health-care workers, who wash their hands multiple times a day, are particularly at risk of hand dermatitis.
Shutterstock

People with eczema, asthma and hay fever are also at higher risk of developing irritant contact dermatitis or experiencing a flare of underlying eczema.




Read more:
Common skin rashes and what to do about them


How do I prevent hand dermatitis?

1. Soap, soap alternative or hand sanitiser?

People with eczema or who have had contact dermatitis before will have more easily irritated skin. While they can still use hand sanitisers, it’s recommended they wash with gentler soap-free washes rather than normal soap.

Soap-free washes contain non-soap-based synthetic detergents (syndets). Syndets have a nearly identical cleansing action as soap, but with the benefit of having the same pH as the skin. This means they’re less likely to remove the oils from the outer layer of the skin and are less irritating.

Soaps have a high pH and are quite alkaline. This disrupts the outer layer of the skin, allowing the soap to penetrate deeper into the skin, thus causing more skin irritation and itching.

Other people who don’t have eczema or a history of contact dermatitis should just use soap. Liquid soaps usually contain fragrances and preservatives, which can cause another type of dermatitis (allergic contact dermatitis), so opt for a plain, unperfumed bar soap.

2. Dry your hands thoroughly

Dry your hands thoroughly, including the webs of your fingers and under your
rings to reduce dermatitis caused by trapped water. Skin irritation and breakdown can occur when there is excessive moisture, soap residues and water trapped between the skin and underneath rings.




Read more:
Coronavirus and handwashing: research shows proper hand drying is also vital


3. Use non-fragranced moisturiser regularly

Moisturisers come in different formulations. While lotions are light in consistency and convenient to use during the day, they will require more frequent applications. Creams and ointments have thicker and oilier texture, are effective for dry hands and are best used overnight.

Fragrances can cause allergic contact dermatitis and are best avoided, where possible.

4. Use alcohol-based hand sanitiser (if you can get hold of it)

Alcohol-based hand sanitiser will reduce your skin’s contact with water, and so lower your risk of dermatitis.

Research in health-care workers shows hand sanitisers cause less contact dermatitis than washing with soap and water.

Sometimes people wrongly believe that when hand sanitiser stings on a paper cut, this means that they are allergic. But this is an irritant reaction and though uncomfortable, it’s safe to keep using it.

Which sanitiser? This usually comes down to personal preference (and what you can get hold of).

5. Use gloves

Use protective gloves when doing household chores, such as washing the dishes or when gardening.

Use cotton gloves when doing dry work, such as sweeping or dusting, to protect your hands and minimise the need to wash them.

Use washing up gloves where possible.
Shutterstock

At night, moisturise your hands than wear cotton gloves. This acts like an intensive hand mask and works wonders for very dry skin. It ensures the moisturiser stays on your hands and increases its penetration into your skin.

What if my hands are already damaged, dry or cracking?

1. Act early

Treat hand dermatitis as soon as it occurs, otherwise it will get worse.

2. Apply petroleum jelly

If you think you’ve lost your nail cuticle (the protective barrier between the nail and nail fold), water will be able to seep into the nail fold, causing swelling and dermatitis.

Use petroleum jelly, such as Vaseline, as a sealant to prevent further water damage. Petroleum jelly can also be used on skin cracks for the same reason.

3. Seek medical help

If there are any red, dry and itchy areas, indicating active dermatitis, seek help from your GP or dermatologist.

They can start you on a short burst of an ointment that contains corticosteroids until the rash subsides.

Prescription ointments are likely to be more effective than over-the-counter creams because of their higher potency.

But you could start with buying 1% hydrocortisone ointment, not cream, from the chemist.




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Sometimes dermatitis can become infected with skin bacteria such as Staphylococcus aureus. Seek medical advice if you experience symptoms such as persistent soreness or pain.

You should also seek medical help if you have severe hand dermatitis not responding to home treatments.

Most GPs and dermatologists are moving to or have started using telehealth so you can consult them using a video call, minimising face-to-face appointments.The Conversation

Celestine Wong, Consultant Dermatologist, Monash Health and Rosemary Nixon, Honorary Clinical Associate Professor, University of Melbourne

This article is republished from The Conversation under a Creative Commons license. Read the original article.