Emergency! But have they washed their hands?

Patients are dying in hospitals as a direct consequence of poor hygiene by medical staff.

How can this be, asks DR ROBERT BAKER

AS the twenty-first century begins, it looks as though doctors have largely forgotten one of the most basic lessons of hygiene. As few as 14 per cent of doctors may wash - and more importantly dry - their hands between patients.

Patients everywhere report filthy unwashed wards and unchanged sheets. I know of at least one doctor who admits to never cleaning or changing the earpieces of her auroscope (ear telescope). Standards have fallen so low that in 1999 three patients in a hospital in Nottingham were accidentally infected by a doctor with malaria, a disease that has not been indigenous in Britain since the 17th century. What has gone wrong?

A look at the past shows how little the medical profession has been aware of its own capacity for spreading infection. The first person to suggest that doctors might spread disease was a Hungarian obstetrician called Ignace Semmelweis.

While working in the Vienna General Hospital in 1850, Semmelweis realised medical students coming straight from postmortems to the delivery room were infecting the mothers with puerperal fever - a bacterial infection which used to kill many expectant mothers. He ordered his students to wash their hands in a chlorinated lime solution before examining the women, and mortality from the fever plummeted. The midwives happily followed suit, but his Austrian medical colleagues were not so receptive. In a sadly familiar medical tradition, they ridiculed and hounded him from his job. He died in a lunatic asylum in Budapest in 1865, a broken man.

Before Semmelweis, Louis Pasteur and Lord Lister began to advance their theories about the spread of infections by microbes, hygiene in the medical world was non-existent. The badge of seniority and experience in surgery was a filthy, stinking frock coat, because the festering bloodstains marked the number of operations performed. Operations frequently ended in devastating infections.

One famously resulted in a mortality of 300 per cent, as the surgeon nicked the fingers of both his assistants with his blade. Both assistants and the patient died of septicaemia.

With Lord Lister's antisepsis, much of that changed. With the appearance of Fleming's penicillin, we began to think that we had conquered infection. As a consequence, gradually we became complacent. With exceptions (such as operating theatres and paediatric intensive care units) the routine washing of hands between patients became a memory. Now, resistant bugs like MRSA (Methicillin Resistant Staphylococcus Aureus) and Vancomycin Resistant Enterococcus are costing us millions every year, not to mention the cost in human lives and misery.

Doctors cannot be blamed entirely for the spread of these germs, but we are a major source.

It is partly due to the incorrect assumption that doctors know which patients are likely to be carrying dangerous germs. The likelihood of any healthcare professional washing his or her hands before or after touching you is related to their seniority and number of qualifications.

Inversely. In other words, auxiliaries are generally cleaner than consultants, who are too clever to bother.

Hands are not the only source of infection from staff. White coats, banned in many canteens, have also been shown to harbour infection, as have underwear, noses and equipment. Nor is wearing gloves a substitute for meticulous washing.

NOT all patients react with enthusiasm to those rare doctors who do observe meticulous hygiene. As a medical student in Bristol I recall a ward round where six of us were required to examine a male patient's genitals (he had a hernia). Afterwards the fastidious, old- school surgeon insisted that we all clean our hands in the ward sink in turn, in full view of the patient. To our surprise the patient rose from his bed, joined the back of the queue, and placed his genitals in the sink, announcing indignantly: "If they are so dirty, I'd better wash them, hadn't I?"

So what will make doctors change their grubby ways? Not education. Basic hygiene is not even on the curriculum in most medical schools; when infection control is taught, it tends to concentrate on the use of antibiotics.

In one experiment, an educational public display about hand- washing was placed by a hospital bed. Several doctors commented about how interesting it was, but not one washed his or her hands as a result.

What does make a difference is the knowledge that we are being observed. In a novel scheme in a New Jersey hospital scientists enlisted the help of patients to try to improve standards, and were able to increase dramatically the frequency with which hand-washing took place. So if your doctor doesn't wash his or her hands before or after examining you - just you tell them.

It's your health.

P Robert Baker is medical registrar in a central London hospital.

Copyright 2000
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