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Advanced Emergency Nursing Journal:
doi: 10.1097/TME.0b013e3181aeddee
From the Editor

The Zen of Hand Washing

Proehl, Jean A.; Hoyt, K. Sue

Free Access

Emergency Clinical Nurse Specialist, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Proehl)

Emergency Nurse Practitioner, St. Mary Medical Center, Long Beach, CA (Hoyt)

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THE ZEN OF INFECTION CONTROL

“Hey buddy, can you spare 15 seconds?” That is what our patients should be asking because that is all it takes to help prevent life-threatening infection by washing your hands or “scrubbing the hub” for 15 s. Unfortunately, in the world of emergency nursing, 15 s seems like an eternity, especially when you have 12 inpatients boarding in the emergency department (ED), a patient with a ST elevation myocardial infarction (STEMI) en route to the cardiac catheterization laboratory, two trauma patients in radiology and one more on the way via helicopter, a septic octogenarian, one wheezing teenager, an agitated patient who is suicidal and wants to smoke, two febrile toddlers vying for your attention, and a waiting room full of patients waiting for ED beds.

Why does it have to be for 15 s? As long as soap and water are involved should not that be enough? A quick wipe with an alcohol swab should kill anything. And besides, how do you know when 15 s is up? You cannot see your watch and wash your hands or scrub a stopcock port at the same time. You have gloves on, so that should protect the patient, right? So little time (15 s); so many excuses.

Caregivers' hands are known to be the most common vector of iatrogenic pathogens. Hubs or access ports in intravenous tubing are also well-known sites of bacterial colonization that may lead to infection (Liñares, Sitges-Serra, Garau, Pérez, & Martin, 1983; Salzman, Isenberg, Shapiro, Lipitz, & Rubin, 1993; Sitges-Serra et al., 1984). Research has demonstrated that 15 s of vigorous scrubbing with alcohol or a chlorhexidine alcohol solution eradicates the bacteria on these hubs (Kaler & Chinn, 2007). Hence, a “scrub the hub” campaign is now underway in many hospitals with the goal of having all access points, hubs, needleless connectors, stopcock ports, and so forth scrubbed with alcohol for 15 s and allowed to air dry before they are accessed.

Ignaz Semmelweiss, an Austrian physician, suggested the relationship between dirty hands and death from infection in the mid-1800s. He saw an immediate decrease in deaths due to postpartum infection when the examining physician washed his or her hands after performing autopsies and before performing gynecological examinations. Unfortunately, Semmelweiss was ignored as well as ridiculed by his colleagues for insisting that cleanliness could prevent disease. His ideas regarding clean hands and instruments were not widely instituted in spite of evidence supporting decreased mortality. Even Florence Nightingale, who promoted sanitation from the beginning as a way to prevent disease, did not initially accept the theory that germs caused disease (Bostridge, 2008; Dock & Stewart, 1938). Although her efforts to eradicate filth were successful in decreasing mortality, she did not believe that a single factor, such as invisible microorganisms, was solely responsible for illness. It was the late-1800s before Pasteur and Koch ultimately convinced most people, including Nightingale, that germ theory was legitimate.

Now, almost 130 years later, we should be appalled that hospital-acquired infections such as catheter-related bloodstream infections, ventilator-associated pneumonia, and catheter-related urinary tract infections are major contributors to mortality and morbidity, not to mention increased healthcare costs. Of course, we do not see these conditions in the ED, but we undoubtedly start some of them. Fortunately, part of this problem is easily addressed by every nurse, every physician, and every healthcare provider. It does not require a stimulus package of cash, more nurses, expensive new equipment or supplies, or even specialized training. All it requires is soap and water or alcohol, and a little time. But time is a precious resource, even 15 s.

On a hectic day a few months ago, I (J. A. P.) found myself reveling in the peace and quiet of the bathroom as I washed my hands. It was a nice break from the noise and crowd in the ED, and I thought perhaps I would linger a bit longer. The warm water and soap on my hands was soothing, and I took a deep breath to clear my mind. It was then that I experienced the Zen of hand washing; a refuge of calm in the midst of chaos. A Google search revealed that I was not the first to discover this state of contemplation while washing my hands; it was described by Watson in 1999 in her book Postmodern Nursing and Beyond in a chapter called “An Interlude: The Zen of Bedmaking.” It occurred to me that I could achieve two goals simultaneously: infection control and stress control. But how to know when 15 s is over lest I linger too long and have the other staff pounding on the bathroom door? Music may be the answer.

We learned last year about the use of music as a mental metronome during cardiac arrest. Specifically, performing chest compressions to the beat of the Bee Gees' song Stayin' Alive resulted in the prescribed rate of 100 compressions per minute and helped rescuers perform more effectively (Matlock, Hafner, Bockewitz, Barker, & Dewar, 2008). You may have been taught that it takes about 15 s to sing Happy Birthday or Twinkle, Twinkle Little Star. But who wants to sing one of those songs 100 times a day? Posting a clock where it is visible from the sink is an option but watching the clock is certainly not calming for most of us. How about another song, preferably something relaxing? The first few lines of Amazing Grace take about 15 s to sing. The 59th Street Bridge Song (Feeling Groovy) opens with particularly appropriate lyrics (“slow down, you move too fast”), and it takes about 15 s to sing through the first “feeling groovy.” There are infinite options as long as you do not sing something inappropriate out loud in front of patients and family. Time yourself singing and figure out which song lyrics work for you; maybe you even want to develop a repertoire of different songs for variety's sake. But what if singing, even silently, is not your thing? Then a mantra may be a better option. There is literature supporting the use of “silent mantram” repetition. This practice leads to improved mental clarity and calmness among other, more spiritual, effects (Borman, 2005). The choice of a mantra, like the choice of a song, is a personal one. Most traditional mantras are associated with religious or spiritual teaching such as the common Buddhist mantra “Om Mane Padme Hum.” Any word(s) could do; maybe repeating the words “peace” or “calm” could become self-fulfilling prophecies. Time yourself so you know how many repetitions it takes to reach 15 s at your desired pace.

Most emergency nurses are constantly multitasking. We know that it increases our stress levels and sometimes leads to an inability to focus on the task at hand. But it is hard to stop something that is so innate and when we are constantly pressed to do more things in less time. The good news is that hand washing and scrubbing the hub do not require close attention; both can be performed pretty much on autopilot. We do have the option of alcohol-based hand rubs that are faster and actually more effective than soap and water in most circumstances (World Health Organization [WHO], 2009) and allow us to at least walk down the hall while performing hand hygiene. However, for those times when soap and water are indicated (when hands are visibly soiled with blood or other body fluids, after using the toilet, or with potential exposure to spore-forming pathogens, such as Clostridium difficile) (Centers for Disease Control and Prevention, 2002; WHO, 2009) or when scrubbing a hub we have a golden opportunity to multitask and reduce our stress while simultaneously helping prevent life-threatening infection. Use that 15 s of hand washing or scrubbing the hub to relax. It may not be much, but it may be all we get.

—Jean A. Proehl, RN, MN, CEN, CCRN, CPEN FAEN

Emergency Clinical Nurse Specialist, Dartmouth-Hitchcock Medical Center, Lebanon, NH

—K. Sue Hoyt, RN, PhD, FNP-BC, CEN, FAEN, FAANP

Emergency Nurse Practitioner, St. Mary Medical Center, Long Beach, CA

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REFERENCES

Borman, J. (2005). Frequent, silent mantram repetition. Topics in Emergency Medicine, 27, 163–166.

Bostridge, M. (2008). Florence Nightingale: The making of an icon. New York: Farrar, Straus & Giroux.

Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in healthcare settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity and Mortality Weekly Report, 51 (RR-16), 1–45. Available from http://www.cdc.gov/handhygiene/

Dock, L. L., & Stewart, I. M. (1938). A short history of nursing (4th ed.). New York: G. P. Putnam's Sons.

Kaler, W., & Chinn, R. (2007). Successful disinfection of needleless access ports: A matter of time and friction. Journal of the Association for Vascular Access, 12(3), 140–142.

Liñares, J., Sitges-Serra, A., Garau, J., Pérez, J. L., & Martin, R. (1983). Pathogenesis of catheter sepsis: A prospective study with quantitative and semiquantitative cultures of catheter hub and segment. Journal of Clinical Microbiology, $21$, 357–360.

Matlock, D., Hafner, J., Jr., Bockewitz, E., Barker, L., & Dewar, J. (2008). 83: “Stayin' Alive”: A pilot study to test the effectiveness of a novel mental metronome in maintaining appropriate compression rates in simulated cardiac arrest scenarios. Annals of Emergency Medicine, 52, S67–S68.

Salzman, M. B., Isenberg, H. D., Shapiro, J. F., Lipitz, P. J., & Rubin, L. G. (1993). A prospective study of the catheter hub as the portal of entry for microorganisms causing catheter-related sepsis in neonates. Journal of Infectious Diseases, 167, 487–490.

Sitges-Serra, A., Puig, P., Liñares, J., Pérez, J. L., Farreró, N., Jaurrieta, E., & Garau, J. (1984). Hub colonization as the initial step in an outbreak of catheter-related sepsis due to coagulase negative staphylococci during parenteral nutrition. JPEN Journal of Parenteral and Enteral Nutrition, $8$, 668–672.

World Health Organization. (2009). WHO guidelines on hand hygiene in healthcare. Available from http://www.who.int/gpsc/5may/en/index.html

© 2009 Lippincott Williams & Wilkins, Inc.

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