By Gary Evans
Healthcare workers — someone may be secretly watching you or an electronic monitor may dispassionately record your handwashing frequency during patient care. It is not that the organization does not trust you — at least, not completely.
Think of it this way: Every time you perform appropriate hand hygiene in healthcare, you are taking the simplest measure of your greatest aspiration — saving patients’ lives. Sanjay Saint, MD, renowned epidemiologist at the University of Michigan, estimates thousands of patient infections and deaths could be prevented with robust hand hygiene programs.1
The standard complaints include sensitive skin, poorly placed sinks and alcohol rub dispensers, too few staff, and too much work. Then, there is the catch-all — no time. Think about that.
For example, a healthcare worker has just treated a patient with multidrug-resistant Acinetobacter baumannii. If she rushes to her next patient without performing hand hygiene, the risk of A. baumannii cross contamination is a dangerous reality. It happens in one form or another every day. Research has shown hand hygiene is performed in full compliance by medical staff only about 40% of the time, meaning in any given patient care situation, 60% of the workers will not have washed their hands.1 Many hospitals encourage patients to remind them.
Healthcare workers generally self-report hand hygiene compliance at much higher levels than the observers watching them. In one Japanese study, healthcare workers reported a handwashing average of 77% before touching a patient. Shockingly, the actual compliance tracked by observers was 12%.2 There will be rebels and resisters within any system protocol, but it seems highly unlikely they all were intentionally lying. Another study revealed healthcare workers are cognitively biased to report a higher rate of handwashing than they perform, but this effect can be mitigated by showing them the reality in numbers of observations.3
If you find constant handwashing burdensome and annoying, you are not alone. But when the hand hygiene connection was first made, it was the difference between life and death. Therein lies the tragic, heroic tale of Ignaz Semmelweis, the 19th century Hungarian obstetrician who made the life-saving connection between unwashed hands and patient deaths. But much as Cassandra from Greek myth, he told a truth that no one would believe.
Bacterial Invasion
Maternal mortality rates were high due to a kind of sepsis known as “childbed,” or puerperal fever, at the Vienna Maternity Hospital where Semmelweis worked for several years in the 1840s. One biographer gave a sense of what this horrific infection was like, describing Semmelweis standing over a patient who had just given birth but was rapidly deteriorating.
“As he stood over her supine figure, Semmelweis noted a sudden onset of uncontrollable shaking throughout her body, accompanied by a chattering of teeth that persisted for several minutes,” the author wrote. “It would take decades of full elucidation of the germ theory before physicians recognized the shaking and chattering for what it truly represented — a sudden invasion of massive numbers of bacteria into the bloodstream. Her uncontrollable rigors signaled the onset of fulminating disease, her calamitous descent over the medical precipice. In this era before antibiotics, her death was a foregone conclusion.”4
There were two maternity clinics at the Vienna hospital: Clinic 1 for the training of male obstetricians, and clinic 2 staffed by midwives. The mortality rate in clinic 1 sometimes was six times higher than clinic 2. Over a six-year period, pregnant women were three times more likely to die in the physician clinic. The mortality rate at clinic 1 was 9.9% vs. 3.3% in clinic 2, Semmelweis wrote in his 1861 book on the subject.5
This difference greatly troubled Semmelweis. He discovered even women who gave birth in the streets of Vienna had a lower puerperal fever mortality rate than those delivering in the hospital.
“To me, it appeared logical that patients who experienced street births would become ill at least as frequently as those who delivered in the clinic,” Semmelweis wrote. “What protected those who delivered outside the clinic from these destructive, unknown endemic influences?”5
A friend and colleague, Jakob Kolletschka, died after he incurred a scalpel wound while instructing a student on performing an autopsy on a patient who had died of childbed fever. The Vienna physicians commonly performed autopsies, which were sometimes then followed by an examination of their pregnant patients. The midwives in clinic 2 did not perform autopsies. Kolletschka’s rapid progression toward death struck Semmelweis with the thought that he had seen this before.
“I could see clearly that the disease from which Kolletschka died was identical to that from which so many hundred maternity patients had also died.” Semmelweis wrote.
Eureka Moment
This insight led to the eureka moment, as Semmelweis reached a conclusion that would save an inestimable number of lives.
“Not the wound, but contamination of the wound by the cadaverous particles caused his death,” Semmelweis realized. “I was forced to admit that if his disease was identical with the disease that killed so many maternity patients, then it must have originated from the same cause. I was compelled to ask whether cadaverous particles had been introduced into the vascular systems of those patients whom I had seen die of this identical disease.”
Realizing this was indeed the case, Semmelweis began washing his hands in chlorinated lime and instructed his students do so before seeing maternity patients.
“In 1848, chlorine washings were employed throughout the year, and of 3,556 patients, 45 died (1.2%),” he found.
It was a remarkable process in reasoning, but Semmelweis also realized how many lives had been lost due to his own contaminated hands.
“I must affirm that only God knows the number of patients who went prematurely to their graves because of me. I have examined corpses to an extent equaled by few other obstetricians,” Semmelweis lamented. “If I say this also of another physician, my intention is only to bring to consciousness a truth that, to humanity’s great misfortune, has remained unknown through so many centuries. No matter how painful and oppressive such a recognition may be, the remedy does not lie in suppression. … None of us knew that we were causing the numerous deaths.”
Despite his own admission of ignorant complicity, rejection by his physician peers was rapid and vitriolic. Semmelweis gave back in kind, and eventually lost his professorship in Vienna, now widely criticized and dismissed for “unscientific” methods at medical conferences. Without the knowledge of microscopic pathogens, some physicians thought disease was caused by vapors and contaminated air. The abject denial that Semmelweis faced resonates with that seen early in the COVID-19 pandemic, both about the disease and the vaccines to prevent it.
Semmelweis’ findings were essentially iatrogenic. He was reporting provider-to-patient fatal infections to some of the very physicians who were culpable. Such a conclusion was roundly rejected, perhaps in part because accepting Semmelweis’ findings amounted on some level as an admission of guilt.
Berating his colleagues for dismissing his findings, Semmelweis grew shriller and was driven into exile as a medical pariah. Isolated and depressed, he declined mentally until he was confined in an asylum in Budapest under harsh conditions in 1865. He died shortly thereafter at age 47 years, having never been recognized for his achievements in his lifetime.
The growing implications of Pasteur’s discovery of the germ theory in 1861 contributed to the long image rehabilitation that followed. Thereafter, Semmelweis was called the “savior of mothers.” There also is a widely used metaphor in his name that attests to his courage while serving as a cautionary tale: “Semmelweis Reflex: The tendency to reject new evidence or new knowledge because it contradicts established norms, benefits, and paradigms.”
REFERENCES
- Saint S. Hand washing stops infections, so why do health care workers skip it? The Conversation. May 17, 2016.
- Hagiya H, Takase R, Otsuka F, et al. Gap between self-evaluation and actual hand hygiene compliance among health-care workers. J Infect Prev 2022;23:239-242.
- Pittman M. Closing the gap between hand hygiene perception & reality. Clean Hands — Safe Hands. 2023.
- Obenchain TG. Genius Belabored: Childbed Fever and the Tragic Life of Ignaz Semmelweis. 2021. University of Alabama Press.
- Semmelweis I. Etiology, Concept and Prophylaxis of Childbed Fever. 1861. English Translation. September 1983. University of Wisconsin Press.
Healthcare workers generally self-report hand hygiene compliance at much higher levels than the observers watching them. In one Japanese study, healthcare workers reported a handwashing average of 77% before touching a patient. Shockingly, the actual compliance tracked by observers was 12%.
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