Hand Hygiene: It's All About When and How

Abstract

From the Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, and World Health Organization First Global Patient Safety Challenge, Word Health Organization Headquarters, Geneva, Switzerland. Received July 25, 2008; accepted July 31, 2008; electronically published August 28, 2008. Infect Control Hosp Epidemiol 2008; 29:957-959 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2910-0010$15.00.DOI: 10.1086/592218 Hand hygiene is the primary measure for infection prevention. When appropriately performed, it reduces the crosstransmission of microbial pathogens and the burden of infectious diseases, both in the community and in the healthcare setting. The major challenge for hand hygiene is compliance, which is usually much less than 50% in most hospitals. Barriers to compliance have been identified at individual, group, and institutional levels. In healthcare settings where epidemiological studies assessed and quantified the role played by such barriers, promotion strategies have been developed and applied successfully—resulting in improved compliance and decreased rates of cross-transmission and infection. To succeed, however, strategies must be multimodal and include at least 5 components: staff education, monitoring of practices and performance feedback, reminders in the workplace, adoption of an institutional safety climate, and, last but not least, a system change—the preferential recourse to the use of alcohol-based hand rub as the new standard for patient care. Hand hygiene with alcohol-based formulations is preferred to hand washing with soap and water in most instances, because it is fast-acting, more efficacious, causes less damage to the skin, and has the major advantage of being immediately accessible at the point of patient care, thus bypassing the time constraint—one of the most critical barriers to hand hygiene in a healthcare setting. Although the majority of studies on hand-hygiene compliance have focused on the time and frequency of action (ie, when to clean hands), only a few have addressed the topic of how to clean hands. In this issue of the journal, Laustsen et al. report on their study that monitored how hand rubbing with alcohol gel was performed at the bedside and corroborated correctness of practice with antimicrobial efficacy. The findings are staggering. Only 55% of staff performed the action correctly, despite being closely monitored by an observer who took imprints of their fingertips before and after hand rubbing with alcohol gel during clinical care procedures. Incorrect practice was associated with a 35% decrease in efficacy, regardless of whether imprints for culture were obtained before the clinical procedure (when hand hygiene was performed to protect the patient) or after (when hand hygiene was performed to protect the healthcare worker or the next patient that he or she would be in contact with). This study adds to previous findings regarding both hand rubbing with alcohol gel and hand washing with soap in suggesting that not only the timing and frequency of hand hygiene must improve, but also its basic qualitative performance. Tools and innovative strategies exist; they just have to be taught and applied. It is obvious that the clinical significance of the findings of Laustsen et al. remains unknown as yet. However, let us stand back and reconcile it with current evidence-based knowledge. Infection control professionals would ideally ask healthcare workers to be 100% compliant with hand-hygiene