Hand Hygiene and Face Touching in Family Medicine Offices
Abstract and Introduction
Background: Family medicine offices may play an important role in the transmission of common illnesses such as upper respiratory tract infections (URTIs). There has, however, been little study of whether physicians teach patients about URTI transmission and what their own actions are to prevent infection. The purpose of this study was to assess the quality of hand hygiene and the frequency with which family physicians and staff touch their eyes, nose, and mouth (the T-zone) as well as physician and staff self-reported behaviors and recommendations given to patients regarding URTI prevention.
Methods: We observed family physicians and staff at 7 offices of the Cincinnati Area Research and Improvement Group (CARInG) practice-based research network for the quality of hand hygiene and number of T-zone touches. After observations, participants completed surveys about personal habits and recommendations given to patients to prevent URTIs.
Results: A total of 31 clinicians and 48 staff participated. They touched their T-zones a mean of 19 times in 2 hours (range, 0–105 times); clinicians did so significantly less often than staff (P < .001). We observed 123 episodes of hand washing and 288 uses of alcohol-based cleanser. Only 11 hand washings (9%) met Centers for Disease Control and Prevention criteria for effective hand washing. Alcohol cleansers were used more appropriately, with 243 (84%) meeting ideal use. Participants who were observed using better hand hygiene and who touched their T-zone less report the same personal habits and recommendations to patients as those with poorer URTI prevention hygiene.
Conclusions: Clinicians and staff in family medicine offices frequently touch their T-zone and demonstrate mixed quality of hand cleansing. Participants' self-rated URTI prevention behaviors were not associated with how well they actually perform hand hygiene and how often they touch their T-zone. The relationship between self-reported and observed behaviors and URTIs in family medicine office settings needs further study.
Family medicine offices have the potential to play an important role in the transmission of common infectious diseases such as upper respiratory tract infections (URTIs). These infections are responsible for significant morbidity, lost work, and health care costs in the United States and are a common reason patients visit a family physician. Americans have 500 million noninfluenza viral URTIs every year, and 22% of these infections lead to an office visit. In addition to providing diagnosis and management during the family medicine visit, clinicians have an imperative to implement precautions to decrease spread, as well as an opportunity for patient education and role modeling to prevent future infections.
All recommendations to decrease the spread of URTIs include hand hygiene, that is, either washing hands with soap and water or using an alcohol-based cleanser. While several studies have documented ambulatory care clinicians' imperfect adherence to hand hygiene frequency recommendations, there are few studies that objectively document the quality of hand hygiene performed by primary care clinicians. The question remains: Are they cleaning their hands in a way that will decrease pathogens on their skin? Even the large amount of literature on hand hygiene in hospitals focuses primarily on adherence to performing hand hygiene, not the actual quality of the hand hygiene.
Less well known is a common step in the transmission of many respiratory pathogens: self-inoculation from the hand to the mucus membranes of the eyes, nose, and mouth (the T-zone). While not all respiratory pathogens are transmitted via this route, many are, including the respiratory syncytial virus and rhinovirus, and anecdotal reports have found that decreased touching of the T-zone results in fewer URTIs. Touching the T-zone often occurs without thought, and studies have documented this in office workers (16 touches/hour) and in grand round attendees, where 1 in 3 picked their nose and 1 in 2.7 rubbed their eyes.
Family physicians and their staff serve as sources of patient education and role modeling. A recent study found that practicing a healthful behavior oneself was the most consistent predictor of physicians counseling patients about related prevention issues. Whether the practice of healthful behaviors to prevent URTIs, such as good hand hygiene and not touching the T-zone, is associated with other behaviors and patient education for URTI prevention is unknown, as are objective data about the quality of hand hygiene and T-zone touching in family medicine practice. Therefore, we observed family physicians and their staff at practices in the Cincinnati Area Research and Improvement Group (CARInG) practice-based research network (PBRN) and assessed the quality of their hand hygiene and the frequency with which they touched their own T-zone. In addition, we surveyed clinicians and staff about self-reported behaviors and recommendations given to patients regarding URTI prevention.