Hand hygiene in the endoscopy unit: a surgical perspective

I was impressed by the recently published article by Santos et al. from Brazil [1] covering adherence to the very underestimated issue of hand hygiene among endoscopy unit healthcare workers. Hand hygiene has been an obsession of surgeons since Semmelweis’s observations in the 19th century. Every interaction, from a surgical procedure to contact with a patient’s environment, starts and finishes with a hand hygiene protocol; or at least it should.

Endoscopists and endoscopy unit nurses often originate from two main medical disciplines – surgery and gastroenterology. This might be an important predictor of hand hygiene awareness and adherence to hand hygiene protocols. Healthcare workers with a surgical background maintain their attitude toward hand hygiene from an environment where hand hygiene is an obvious requirement that is supported by clinical, microbiological, and cost-effectiveness data. They would be expected to have the same attitude in everyday endoscopy practice. Conversely, endoscopy unit healthcare workers who originate from a gastroenterology environment are probably not as obsessed with hand hygiene, and therefore implementation of hygiene procedures in the endoscopy unit might be considered more of a “new standard” rather than an ingrained practice that is automatic.

Over the past decades, endoscopy has become an interventional discipline often substituting or reproducing surgical procedures. Transmural drainage/debridement of walled-off pancreatic necrosis and percutaneous endoscopic gastrostomy placement are just examples of procedures that involve manipulations outside the lumen of the gastrointestinal tract. Endoscopic procedures range from purely diagnostic examinations through to interventional procedures, with natural orifice transluminal endoscopic surgery procedures being at one extreme. In purely diagnostic examinations, especially in an outpatient setting, emphasis on restrictive hand hygiene procedures might not be completely convincing. In addition, the relatively rare transmission of infections in endoscopy and the fact that transmissions are mainly attributable to the equipment must also be considered in any cost-effectiveness model. However, every diagnostic examination can, within seconds, become an interventional procedure. Therefore, every endoscopy might become a surgical field requiring not only appropriate hand hygiene but also protective glasses and masks. The real value of adhering to these protective measures remains unknown. I dare to suggest that in interventional endoscopic procedures, even surgical hand disinfection might be justified in prevention of infections transmitted from healthcare workers to the patient and vice versa.

In summary, hand hygiene standards and guidelines designated for implementation in endoscopy units seem to be an emerging need to be faced by hospital policies, and national and international societies. I therefore congratulate our colleagues from Brazil on starting a discussion on such an important and so far neglected issue, which has important implications for healthcare workers, health care authorities, and ultimately for our patients.

• References

• 1 Santos LX, Souza Dias MB, Borrasca VL et al. Improving hand hygiene adherence in an endoscopy unit. Endoscopy 2013; 45: 421-425