AS a hospital epidemiologist, my inclination when I reviewed the article by Pittet et al. entitled “Hand-cleansing during Postanesthesia Care”1was to say, “It's about time someone addressed this issue in the PACU”! In contrast, readers of the Journal may be asking, “What's the big deal? These authors haven't demonstrated that poor compliance with hand-cleansing, or hand hygiene, in the PACU is linked to subsequent nosocomial infections.” If that is how you responded, you are correct when you say the authors did not prove that poor compliance with hand hygiene caused nosocomial infections. In fact, their goal was simply to evaluate compliance with hand hygiene in their PACU. They accomplished this goal and documented that compliance with this basic infection-control measure was as low or lower than that previously reported from intensive care units (ICUs).
Before I go further, I want to congratulate the authors for addressing this difficult topic. I also want to congratulate nurses and physicians working in PACUs who take hand hygiene seriously. That said, I'd like to address skeptics in the reading audience. I also would like to address the issue of time—because it is not only about time someone did a study on this topic, but it is also time that makes this a difficult topic to study, and time (or lack thereof) that may prevent some staff from practicing good hand hygiene.
Given the brief time that patients are in the PACU, it will be difficult to prove that specific nosocomial infections occurring while the patient is in the surgical ICU or on the surgical ward were caused by the PACU staff's failure to perform hand hygiene appropriately. However, data from ICUs indicate that patients typically acquire pathogens from the hands of healthcare workers and that hand hygiene decreases the transmission of these organisms and prevents nosocomial infections. 2,3I cannot envision a universe in which rules that apply in ICUs do not apply in PACUs. Thus, a Gram-negative organism may be carried on a PACU nurses’ hands from the Foley catheter to the hub of the central venous catheter and from there into the bloodstream of a patient. When signs and symptoms of bloodstream infection are manifest, the patient will be in the surgical ICU. The infection-control program will report the infection to surgical ICU staff, and PACU staff will never receive feedback about that or any other infection.
This Editorial View accompanies the following article: Pittet D, Stéphan F, Hugonnet S, Akakpo C, Souweine B, Clergue F: Hand-cleansing during postanesthesia care. Anesthesiology 2003; 99:530–5.
PACU staff members are extremely busy caring for patients who are unstable, in pain, have numerous invasive devices, and require substantial nursing care. Obviously, if the choice is between performing hand hygiene and performing a task that will save the patient's life, staff members should save the patients’ life. However, this author suspects that staff members infrequently must choose between performing hand hygiene and saving the patient's life. Instead, I believe that PACU staff and other staff neglect to cleanse their hands because they have not been trained to identify all situations in which hand hygiene should be performed or because the culture in the unit is such that staff members do not put a high priority on this practice.
The argument that PACU staff members do not have time for hand hygiene is mitigated in part by the alcohol-based hand-hygiene products available in many hospitals. These products can be placed at the bedside so that staff members do not even need to cross the room to cleanse their hands. Moreover, Voss and Widmer documented that these products reduce by 50–75% the time needed for hand hygiene in an ICU. 4
Two recently published studies are pertinent to the study by Pittet et al. Rogues et al. documented that 33% and 41% of patients carried pathogenic organisms in their nares or on skin adjacent to their surgical sites when they were admitted to the PACU and when they were discharged, respectively. 5Nineteen percent of staff also carried pathogenic organisms. These investigators concluded that cross-contamination could occur in PACUs and that staff needed education regarding hand hygiene, isolation precautions, and environmental cleaning. Hajjar and Girard conducted surveillance for nosocomial infections related to anesthesia, which they defined as infections occurring within 72 h of a general or regional anesthetic procedure. 6They identified 25 infections—12 respiratory, 9 vascular catheter–associated, 2 eye, and 2 mouth—for a rate of 3.4 infections/1,000 patients. The infections could have been acquired in the operating room, PACU, or surgical ICU. Although we can't prove that they originated from errors in the PACU, we also can't prove that they didn't.
The PACU is usually an open ward without barriers, such as walls, between patients to remind staff members that they need to cleanse their hands when moving from one patient to another. Also, patients usually are not alert enough to ask their caregivers whether they have cleansed their hands. In addition, numerous articles have outlined the infectious hazards that PACU staff encounter in their routine work. 7Hand hygiene and other basic infection-control precautions protect not only patients but also healthcare workers. Thus, it would behoove PACU staff to understand the risks they face and to use infection-control precautions to prevent exposures. The old adage, an ounce of prevention is worth a pound of cure, applies in this setting. Infection-control staff members are often amazed when healthcare workers who have been exposed to infectious agents reply “I didn't have time” when they are asked why they did not put on personal protective equipment. Yet they have time to demand prophylaxis after the exposure.
It is time that anesthesia and PACU staff members—both physicians and nurses–view themselves as links in the infection-control chain. A chain is only as strong as its weakest link. PACU staff members do not want to be the weakest link in the infection-control chain, but their compliance with hand hygiene places them in this position. To upgrade the strength of their link, PACU staff members must change the culture of their units such that good hand hygiene is considered an essential part of the job. Physicians, in particular, must become good examples. A recent study in Germany found that 70% of healthcare workers attending an infection-control meeting thought that physicians and other supervisory staff were poor role models. 8Infection-control specialists may be able to suggest changes that improve practice, but they cannot design the best solutions because they do not work in PACUs. PACU staff, who know how the work is done and know the limitations of staffing, space, and time, are the only ones who can develop effective strategies. In addition, administrators must provide adequate staffing levels and training. The latter are important not only to improve infection control but also to maintain or improve the overall quality of care and to provide a safe work environment for staff.
Pittet and colleagues have laid down the gauntlet to PACU staff and to hospital administrators. It remains to be seen whether those staff and administrators will pick it up, own the problem, and find creative solutions, or whether they will refuse to acknowledge their place in the great chain of infection control.