New insights for improving hand hygiene practices.

Abstract

Publication of the Guideline for Hand Hygiene in Health-Care Settings, developed by the Healthcare Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control (APIC), and the Infectious Diseases Society of America (IDSA),1 has stimulated interest in improving hand hygiene practices in healthcare facilities. Endorsement of the Guideline by the Joint Commission on Accreditation of Healthcare Organizations should serve as additional impetus for institutions to develop and implement multidisciplinary programs to increase adherence of healthcare workers (HCWs) to recommended hand hygiene measures.2 Although the Guideline provides a comprehensive review of published evidence on the subject, there is still much to be learned about hand hygiene practices and how to improve them. Several articles3-7 appearing in this issue of Infection Control and Hospital Epidemiology provide new insights that should be incorporated into hand hygiene improvement programs. For approximately 30 years, it has been assumed that the importance of handwashing or hand antisepsis (using antimicrobial soap and water or an alcohol handrub) depended to some extent on the type of patient care activity being performed. In the 1970s, Fulkerson described 15 types of activities that were assumed to cause increasing degrees of hand contamination.8 Activities ranked 1 to 4 or 1 to 6 were considered “clean procedures” and those with higher rankings were classified as “dirty procedures.” However, the Fulkerson scale has not been validated by culturing HCWs’ hands following each of the 15 categories of contact. One earlier study that evaluated several types of patient care activities established that the rate and degree of hand contamination does vary for different types of contact.9 In this issue of Infection Control and Hospital Epidemiology, several articles provide additional data on contamination of HCWs’ hands and the frequency with which hands are cleaned after various patient care activities. In a study conducted in a neonatal intensive care unit, Pessoa-Silva et al.3 established that hand contamination was greatest during diaper changes and respiratory care, followed by direct skin contact and contact with other types of body secretions. These findings help validate the ranking of procedures described in the Fulkerson scale. However, they demonstrated that some clean procedures (eg, contact with inanimate objects in the vicinity of a patient) may cause hand contamination. The latter finding confirms earlier studies conducted in different patient care settings.9-12 The authors found that colony counts on the hands of HCWs caring for neonates increased an average of 24.5 colony-forming units per minute when gloves were not worn.3 Hands became contaminated with up to 100 colony-forming units after only 2 minutes of respiratory care, changing diapers, or having direct skin contact. Wearing gloves reduced, but did not eliminate, hand contamination, a finding reported by others.9,10,13,14 The authors also emphasized the need to clean hands between sequences of care performed on the same patient, as recommended in the Guideline.1 The study by Wendt et al.5 in this issue of Infection Control and Hospital Epidemiology determined the frequency with which HCWs cleaned their hands with an alcohol handrub following the 15 types of patient activities described by the Fulkerson scale. Of interest, the authors found that the greater the predicted risk of hand contamination, the more likely HCWs were to clean their hands. This observation provides new evidence that the Fulkerson scale correlates fairly well with HCWs’ attitudes about the need to clean hands after various activities, as suggested in earlier studies.15 However, several findings in the study by Wendt et al. were of concern. Some nurses spent time unnecessarily cleaning their hands after activities with little risk of contamination. Also, intensive care unit personnel performed hand antisepsis less than 40% of the time when having direct contact with patient secretions or contact with objects contaminated with patient secretions.