If Content is King then Context is Queen

If Content is King then Context is Queen

In April 2016 a study completed by SHIP (Safeguarding Health through Infection Prevention) researchers at Glasgow Caledonian University (GCU) made the headlines as it produced the first evidence, in a randomised controlled trial (RCT), that the World Health Organization’s (WHO) 6-step hand hygiene guidance is more effective in reducing residual bacterial load on healthcare workers hands than the 3-step technique.

There are two ways to wash your hands?

Yes, there are currently two internationally recommended techniques for healthcare staff undertaking direct patient care reported for hand-hygiene: the 6-step guidance by the World Health Organization (WHO) and the 3-step technique by the United States’ Center for Disease Control and Prevention. However previously, neither technique had a very limited evidence base to support their effectiveness.

And the results are in

This new applied research showed that the 6-step technique was superior to the 3-step technique in reducing the residual bacterial load after alcohol-based hand rub hand hygiene. This reduction was not related to the area of the hands coverage, time taken to perform the technique, type of organism or staff group.

This was an important finding since hand-hygiene is the cornerstone of infection prevention and control and yet very little evidence exists to support the best technique. Therefore the SHIP researchers and GCU felt that it was important to share this information with the world.  The study itself was published in “Infection Control and Hospital Epidemiology”, the journal of the Society for Healthcare Epidemiology of America, and to ensure maximum impact of this publication, GCU send out a press release. This is where it got interesting!

It was headline news


Media coverage was plentiful and diverse. It featured in nearly 100 news outlets, as well as social media from all over the world (e.g. United Kingdom, Denmark, New Zealand, the United States, Sweden, India, South Africa, Poland, Brazil, Japan) and from a variety of different backgrounds (e.g. medical, infection control, science, lifestyle).

Headlines included, “You’ve been washing your hands wrong” (NY Times); “You’ve been washing your hands wrong your whole life” (IFL Science), “The right way to wash your hands” (Wall Street Journal) and “WHO’s six-step hand hygiene technique superior to CDC’s three-step technique” (Healio).

Just follow the instructions

Most of the publications summarised the paper well and there was also a focus on the interesting finding that only 65% of participants in the study followed the entire 6-step process even though the instructions were in front of them –the focus of a follow-up study we are currently beginning. However this current RCT found that the 6-step technique, even when not performed completely or perfectly, i.e. at 65% compliance, was still superior to the 3-step technique. It could be to do with the sites of the hand more frequently missed by the 3 step (the back of the index and the middle finger of the right hand are significantly less frequently missed by 6 steps compared to 3 steps); however, there is a need for additional research to explore this further.

I simply don’t have the time

However, some took the paper out of context and concentrated on the amount of extra time the 6-step technique took compared to the 3-step. One online science magazine worked out that, as the 6-step technique takes 24% longer to complete, you would spend an extra 7.5 seconds per wash. Therefore if you washed your hands 8 times per day you would spend an extra 6 hours a year washing your hands (IFL science).  In fact we make comment on this in the paper, as those doctors and nurses with 100% compliance with the 6 step technique had a significantly greater reduction in bacterial load, with no additional time or difference in coverage, compared to those with 65% compliance with 6 step technique. This means that it is the technique rather than the length of time that is important, meaning there is real merit in investing effort in further improving healthcare workers compliance with the 6 step technique.

It’s just a matter of opinion

Not everyone saw the importance of the study, both for the prevention of Healthcare Associated Infections (HAIs) and in preventing the public from getting common colds and food poisoning, with one opinion writer in The Sunday Times stating, “Honestly, I wash my hands of these bozos”. The public’s reaction to some of the posts was also interesting. One online commentary forum began with, “This world is doomed. NOW WE NEED SCIENTISTS TO TEACH US HOW TO WASH OUR HANDS????” However these discussions often led to comments about how people are “disgusting” and often don’t wash their hands which then led to discussion about how this could be improved, ending with sentiments such as, surely if it helps then it’s worth the extra time. This debate in itself raised the awareness of hand hygiene.

There’s no such thing as bad publicity

The 6-step technique may be “overwhelming” and “complicated” as quoted within the press but a common sense approach is taken with many of the journalists who featured our study. They recommended, “at the very least you spend 10 or 15 seconds working up a good lather” and “get scrubbin”(Bustle.com) or, as Refinery29 explained, “it’s important to remember though, that even if your bathroom is pretty gross, you’re probably not dealing with hospital-level scary bacteria. So while we should all probably be using the six-step technique to keep as safe as possible (especially if we’re handling food or in the bathroom), we also realize that’s probably not going to happen every time. So wash your hands as well as you can with soap and warm water, but don’t freak out if you’re not hitting every single one of those six steps.”

Promoting hand hygiene to healthcare workers and the public is the real intention of the publicity surrounding this study and that seems to have been achieved.

Here is the link to the actual study:

A Pragmatic Randomized Controlled Trial of 6-Step vs 3-Step Hand Hygiene Technique in Acute Hospital Care in the United Kingdom
Jacqui S. Reilly, Lesley Price, Sue Lang, Chris Robertson, Francine Cheater, Kirsty Skinner and Angela Chow June 2016
Infection Control & Hospital Epidemiology, ,Volume37, Issue06, June 2016, pp 661-666

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