Promotion of hand hygiene: magic, hype, or scientific challenge?

Abstract

The compliance of healthcare workers (HCWs) with hand hygiene practices is universally low.1 The challenge of promotion of hand hygiene could be summarized in two simple questions: (1) How can we change the behavior of HCWs? and (2) How can we maintain such change? Predisposing, enabling, and reinforcing factors should be taken into account for the successful promotion of hand hygiene and prevention of nosocomial infections.1-3 Among predisposing factors for noncompliance with hand hygiene are physician and nursing assistant status (rather than a nurse), glove wear, skin irritation by hand hygiene agents, and the critical care setting, particularly when heavy workloads exist with an increased number of opportunities for hand hygiene per hour of patient care.1,3,4 Time constraint was the most influential parameter in the largest epidemiologic survey conducted.4 Self-reported factors for poor adherence with hand hygiene include poor accessibility of sinks or a lack of convenient tools for hand hygiene, lack of knowledge, disagreement with or even skepticism about recommendations, the feeling that hand hygiene might interfere with HCW–patient relations, lack of scientific information reporting a definitive impact of improved hand hygiene on nosocomial rates, the impression that the risk for cross-transmission is low for the patients, the belief that glove use dispenses from hand hygiene, and the idea that patient needs take priority over hand hygiene.1-5 Additional key factors for noncompliance are forgetfulness, the lack of a role model in colleagues or superiors, and the absence of an institutional priority for hand hygiene. On the basis of reported experiences, strategies for the successful promotion of hand hygiene in hospitals include educating HCWs; monitoring HCW compliance and providing performance feedback; placing reminders in the work place; improving engineering control; promoting and facilitating care of the skin of HCWs’ hands; and avoiding overcrowding, understaffing, and excessive workloads.1,3,5,6 Other administrative, institutional, and individual measures have been suggested, such as rewarding HCWs who comply, having individual HCWs and institutions actively participate in the promotion of hand hygiene, enhancing individual and institutional self-efficacy, and creating a climate of institutional safety.1-3,5-7 Furthermore, ongoing commitment from opinion leaders in the hospital to support the promotion of hand hygiene is fundamental.8 Last, but not least, promotion strategies must combine several of these parameters (ie, be multimodal).1-3,5,9 Among enabling factors, engineering control must be considered for the successful promotion of hand hygiene. In particular, it involves making hand hygiene easy, convenient, and possible in a timely fashion.1,3,5 New guidelines propose waterless hand antisepsis as the standard for hand hygiene.10 Alcohol-based hand rubs are the preferred hand hygiene agents because they reduce bacterial counts on hands more effectively than plain or antimicrobial soaps; can be made more accessible than sinks and other hand washing facilities; require less time for action; and cause less skin irritation and dryness than soap and water.1,3,6,8,10-13 Promoting and facilitating care of the skin of HCWs’ hands is part of the recommended strategies. Although a simple change in the hand hygiene agent being used, such as the introduction of a hand rub, might help, convincing HCWs not only to use it, but to continue using it remains a major challenge. Among reinforcing factors, routine observation of HCW compliance and performance feedback has been extensively studied and reported.10 It is also part of proposed frameworks that list strategies for the successful promotion of hand hygiene.1,3,5,9 Although individual, inservice, group, ward, department, and hospital-wide feedback has been used as a