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Explore This IssueOctober/November 2013
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During the 20 years following the watershed outbreak event at Jack In The Box in 1993, the industry learned a lot about hand hygiene, cross-contamination, and a new generation of pathogens.
The newcomer, E. coli 157:H7, got center stage as the country and the world watched this outbreak play out. It awakened the public as well as the industry that a foodborne illness is a lot more serious than a fleeting stomach ache.
Twenty years earlier the Norwalk virus grabbed the headlines for the first time. Since then, with its name shortened to norovirus, it has maintained the headlines by soaring to the top of the list of outbreak causing pathogens. It regularly sends cruise liners back to port, invades nursing homes, and shutters restaurants.
In 2009, the CDC launched NORS, a web-based system to collect foodborne outbreak information and CaliciNet, a network of labs to feed a national database.
The more that is learned the louder the cry for better handwashing, both in quality and frequency.
Norovirus serves well as a focal point in setting handwashing criteria in food service and retail establishments. It is one of the smallest of pathogens and among the leaders in virulence. If the hand hygiene process is effective in removing or killing this microorganism, it will be capable of handling all the other common hand contaminants.
No Standards. No Measurement.
The lack of hand hygiene standards blunts the development and implementation of enhanced hand hygiene tools. What is a clean hand? What is considered an effective handwash? Without definitions like these, product research and development is discouraged.
Obvious advancements like touch-free electronic faucets are slow to be picked up by operators where short-term cost and efficiency are measured factors in their success and handwashing isn’t. The incentive to encourage more handwashing is lacking. Efficiency trumps handwashing.
Some water saving initiatives even collide with best practice handwashing. A faucet flow of 2.2 gallons per minute (gpm) is very effective in accelerating good cleaning and thorough rinsing. Without all the information, some operators install restrictors, some down to 1.0 gpm. Now the time-short worker, frustrated by the low flow, walks away with a minimum of rinsing. It is soap residues that are a major cause of dermatitis. One sure way to minimize handwashing is to have it seen as the reason for dry, cracked skin.
A reliable electronic faucet is the better answer for those seeking water savings. This touch-free option delivers water when you need it and the flow stops while scrubbing, saving nearly a gallon of water for a single 20 second wash.
The lack of numeric standards obscures the patterns predictive of a breakdown in the system. “Is our deli running at a safe or risky level?” The sign on the restroom mirror to remind workers to wash their hands and the certifications for the persons-in-charge do little to alert the management that its handwash process is trending down and about to break. Their first indication may well be the calls from the hospital’s emergency room.
No Process. No Process Control.
In most food service and retail food establishments, process is king. It alone controls the risk, with one exception. There is no process when it comes to handwashing. Attempts are made to train employees why, when, and how to wash their hands. Training is budgeted annually. The trainers are given everything they need but no standards and no method to monitor the process.
A CDC observational study in the Journal of Food Protection found that a food worker would have to wash 8.6 times per hour to be compliant with The Model Food Code. This challenges the FDA and industry as both agree this is likely never to be achieved. Is compliance really that bad or is the Food Code overestimating many risks?
Advances have been made in making it easier and more inviting to wash hands. Handsoap formulations have advanced to provide effective cleaning while using skin-safe ingredients. This, together with touch-free dispensers, encourages frequent use.
Better papers, dispensed by no-touch electronic dispensers, are ideal for handwashing, affording a measured degree of friction to actually complete the cleaning-drying process.
Value-engineering and “green” initiatives periodically compete with handwashing’s best practice choices and they frequently win. This harkens back to the lack of standards. A purchasing agent may get rewarded based on finding a lower price for a 60 percent recycled paper. No one bothers to check that the new paper crumbles when wet and discourages handwashing.
The false-saving of air-dryers is witnessed regularly in food service and retail restrooms, the very restrooms used by the staff as well as the public. Both, along with the quality assurance department and the health inspector, prefer paper towel drying but are muzzled by either a “green” argument or over an unsightly presence of paper on the floor. If that decision maker could only see the pathogens marching out through the restroom door on the hands of the great unwashed.
Hospitals are no better than food service when it comes to handwashing but they do have a useful organizational tool to protect best practices—the Infection Control Committee. When changes are proposed to a process like handwashing, they must approve. Restaurants and retail would be well advised to consider a three member Handwash Process Control Committee, bringing quality assurance, operations, and risk management together to help control the risk.
The nailbrush raises another controversy. It simply can be used to accelerate good cleansing, particularly around the nail bed. However, the health inspector may request that the brush be tethered and stored in a sanitizer solution. Technically this is a good idea but the difficulty in keeping the sanitizer level at an effective range without risking skin damage makes it a bad idea. This method deters nailbrush use and the grimy appearance of the tethered brush may discourage use of the handsink altogether.
Some operators use an easily cleaned, self-cleaning fused bristle nailbrush. It is simply recycled by running it through the dish machine, power soak, or microwave as it has no staples.
Norovirus serves well as a focal point in setting handwashing criteria in food service and retail establishments.
Expanding Role of Hand Sanitizers
Hand sanitizers are one of the most under-utilized interventions in restaurants, convenience stores, lodging, and supermarkets. When operators want to add a further level of confidence and safety, these alcohol based, code compliant formulations have many advantages based on their versatility and convenience.
They can be applied directly at the handsink following a thorough wash. With the soil removed, this category of germ killers is highly effective. It is true that there is a wide range of performance when dealing with killing norovirus. Christine Moe, PhD, at Emory University in a break-through study discovered that human norovirus is much harder to kill than its calicivirus surrogate. She also identified one particularly effective formulation, breaking the myth that alcohol hand sanitizers are ineffective with norovirus.
Norovirus enters restaurants and delis through the front door as well as the employee entrance. Once inside, they welcome new hosts, contaminate shared surfaces, and threaten the wellness of both customers and employees.
Washing with alcohol hand sanitizer when water is not readily available has proven to be as effective as soap-water handwashing when followed by a second application of the sanitizer.
Multi-unit operations often know what’s best based on third-party research but can’t implement because some of the inspectors across the country in over 3,000 jurisdictions are misinformed or waiting for formal codification. Thus the risk of citations and attendant administrative costs protect the status quo. The cards are stacked against innovation.
The handsink itself is too often considered a commodity and selected on price alone. Soon after installation operators will be adding splash guards as the water stream hits the flat shallow bottom, another discouragement to frequent handwashing. Deep draw handsinks minimize the splash and completely evacuate, leaving no soapy contaminated residuals to grow bacteria. Best practice handsinks also have a bacteriostatic surface which not only arrests the growth of germs but makes the unit easy to clean and very attractive, inviting more frequent use.
Proper gloving adds safety to the handwashing/hand hygiene process. The public is the primary driver of the need for gloves, particularly around sandwich making and other handling of ready-to-eat foods.
Proper gloving first means selecting the right glove for the task, the right size and from a reputable supplier whose quality control spans the Pacific. The temptation to treat gloves as a commodity is tempered by trials.
Tear strength, cut resistance, comfort, ease and speed of donning, and doffing all are important considerations. Changing gloves from task to task is the challenge. Getting employees to change gloves can be harder than achieving handwash compliance. The better the glove, the more likely a timely change.
Infrequent glove changing is largely due to time constraints but the food codes and health inspectors provide another factor. If you are “caught” wearing a glove, clean or contaminated, you earn a positive checkmark. A bare hand earns you a citation from the inspector and a reprimand from your supervisor.
Value-engineering and “green” initiatives periodically compete with handwashing’s best practice choices and they frequently win.
Monitoring measured standards closes the risk-based loop of actions—Assess Risk, Set Standards, Optimize, Train, Monitor. Without it, training is largely wasted and the opportunity to motivate and reward is lost.
Monitoring the quality of the handwash is a key understanding set up in day-one training. Workers learn why and when to wash as well as it being a job-critical measured standard. This is best done by selecting a very personal and visual training option. For example, Handwashing For Life Institute’s ProGrade system uses a UV traceable lotion so the trainee experiences what it takes to achieve the operator-set standard referred to as ServeReady Hands.
The quality of the wash is greatly affected by scrub time. Here a physical timer can help. Some electronic options will monitor elapsed wash time as well as frequency.
Handwash frequency has been largely limited to observation, a major contributing factor to low compliance. Technology assisted case studies commonly demonstrate a doubling of compliance rates when accompanied by a solid implementation process. Science is providing a growing bank of options, including video, infrared, radio frequency identification, and improved manual systems.
Finally, what about those frequently touched seldom cleaned surfaces? These are areas where bacteria can comfortably multiply and reach levels more likely to contain the pathogenic toxins. Setting effective protocols and monitoring results with reliable adenosine triphosphate system helps keep hands clean. Equipment quality, ease of use, and reliability are important characteristics. Without consistency and reliability, this method becomes a disappointing random number generator.
Away-from-home wellness is often in the hands of those serving the public when they dine. The CDC agrees and points out that “Handwashing is the single-most important means of preventing the spread of infection.”
Mann is executive director at the Handwashing For Life Institute. Reach him at firstname.lastname@example.org.
References Furnished Upon Request