Encouraging doctors and nurses to wash their hands frequently has always been considered an effective way to curb the spread of infection in hospitals and other health facilities.

But a research letter published Monday in JAMA Internal Medicine points to another key group of people who aren't always keeping their hands so clean and probably should: patients.

Researchers focused on inner-city Detroit and looked at patients who went from hospitals to post-acute care facilities — places like rehabilitation centers, skilled-nursing facilities, hospice and long-term care hospitals. They found that almost 1 in 4 adults who left the hospital had on their hands a superbug: a virus, bacteria or another kind of microbe that resists multiple kinds of medicine.

While in post-acute care, about 10 percent of patients picked up another superbug. Of those who had superbugs, 67 percent still had them upon being discharged, even if they hadn't gotten sick.

These findings add to a growing body of research about hand hygiene and the patient's role in infection transmission, and speak to a problem with health care facilities — they can increase the odds of getting sick.

The paper's authors suggest a so far underused strategy for addressing that concern: getting patients to wash their hands.

Conventional wisdom has long held that doctors and nurses who go from patient to patient are most likely to transmit germs. As a result, few health care settings really make patient hand-washing a major priority, said Leah Binder, president of the Leapfrog Group, a nonprofit organization that grades hospitals on patient safety.

The paper, she said, "really requires an immediate response" from safety advocates.

"We have to revise hand hygiene policies to include patients. One of the main strategies on hand hygiene is to make it easy to wash hands," she said. "Most hospitals have either sinks or dispensers near the door of every room, so that it's very easy for a provider walking in to immediately wash their hands. Do we make it easy for patients to wash their hands? I doubt it."

Beyond that kind of architectural change, signs should be visible around facilities to remind patients about hand washing, she said.

But just because patients are carriers of superbugs doesn't mean they will get sick, said Lona Mody, a professor of internal medicine at the University of Michigan-Ann Arbor, and the study's corresponding author. There needs to be more research to measure the relationship between carrying germs and falling ill, she added.

If you have superbugs on your hands, though, you probably have them elsewhere, too — in your skin or in your gut, said Louise Dembry, president of the Society for Healthcare Epidemiology of America and a professor of medicine, infectious diseases and epidemiology at Yale. Having them on your hands makes them easier to spread.

Plus the patients in these kinds of facilities are, almost by definition, more vulnerable to infection, Binder said — they've just come out of a hospital where they needed a high level of care.

"I find it not difficult to imagine" that a number of these patients will end up with serious infections, she said.

Spreading germs is also easier to do in post-acute settings, Dembry noted, since patients are more likely to interact with each other. Patients are encouraged to move around more and, as a result, more likely to touch medical equipment and furniture, among other things, which can spread the germs, Mody said. Overall, these circumstances increase the odds of transmitting germs and up the need for better hand-washing protocols.

Dembry added that hand washing can be only one part of any strategy to prevent infection. Medical tools and machines need to be kept clean. Culturally, patients should feel comfortable asking each other if they've washed — and steer clear if they might be infectious.

As health care facilities are increasingly evaluated on how well they care for patients, they should be rewarded for things like promoting clean hands, Mody said.

For instance, "if an institution has a program that enhances patient hand hygiene, the quality of that place should be considered higher," she said.

This story was produced as part of a partnership between NPR and Kaiser Health News, an independent health journalism organization.

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