Hand Hygiene Guidelines Research Articles

Effectiveness of Hand Hygiene Education in a Basic Nursing School Curricula

Although hand hygiene (HH) is the cheapest and simplest tool for the prevention of hospital-acquired infections, poor HH compliance has been reported among health care professionals. A variety of factors influence the compliance with HH guidelines, the most important being the quality of the basic nursing education. The aims of this study were to analyze the effectiveness of the basic nursing education in relation to HH, and to explore the skills and attitudes toward HH among nursing students in praxis. A mixed-method approach using a cross-sectional survey combined with observation and curricular analysis was used. A total of 188 nursing students participated in the study. Content analysis revealed significant deficits in the quality of HH-related information in basic nursing educational programs. Our results correlate directly with the reported insufficient levels of HH knowledge and the associated poor HH compliance by students during their training in clinical settings; as shown in observation and questionnaire-based surveys. The lack of compliance with HH standards among students lead to poor compliance among health care professionals in praxis. Consequently, the role of educational institutions in the prevention of hospital-acquired infections is significant, if the effectiveness of HH education is to be improved.

Hand-hygiene practices in the operating theatre: an observational study

The current prevalence of healthcare-associated infections (HCAIs) is a major public health concern. Patient contact in the operating theatre (OT) can contribute to HCAI via microbial contamination. The application of hand hygiene is effective in reducing infection rates. Limited data are available on adherence to hand-hygiene guidelines by OT staff. Covert direct observations of OT staff at an academic medical centre were performed by a single, trained observer. The primary outcome was the frequency of hand-hygiene application by OT staff, including anaesthesiologists, anaesthesia nurses, surgeons, surgical nurses, and medical students. 'Sterile' scrubbed staff members were excluded. The following hand-hygiene opportunities were monitored: (i) entering or leaving the OT; and (ii) before patient contact. Furthermore, the frequency of 'potential contamination' was recorded (touching OT implements after contact with patient/patient body fluids without the subsequent application of hand hygiene). We recorded non-surgical glove usage for invasive procedures, for example, intubation or insertion of intravascular devices. Finally, we collected qualitative data on incentives for hand hygiene. A total of 28 operations were observed (60 h of observations). On average, 0.14 hand-hygiene applications per hour per staff member were witnessed. Upon entering or leaving the OT, hand hygiene was performed in 2% (7/363) and 8% (28/333) of opportunities. Frequent interactions between patient, staff, and OT environment were observed. Adherence to hand-hygiene guidelines by OT staff was extremely low. This potentially exposes patients to microbial transmission, HCAIs, and patient harm.

Effectiveness of an audible reminder on hand hygiene adherence

Multimodal interventions aim to improve health care workers' adherence to hand hygiene guidelines. Visitors are not primarily targeted, but may spread epidemic infections. Effective interventions that improve the adherence of visitors to hand hygiene guidelines are needed to prevent the transmission of epidemic infections to or from health care environments. An electronic motion sensor-triggered audible hand hygiene reminder was installed at hospital ward entrances. An 8-month preinterventional and postinterventional study was carried out to measure the adherence of hospital visitors and staff to hand hygiene guidelines. Overall hand hygiene adherence increased from 7.6% to 49.9% (P < .001). The adherence of visitors and nonclinical staff increased immediately from 10.6% to 63.7% and from 5.3% to 34.8%, respectively (P < .001). Adherence of doctors, nurses, and physiotherapists increased gradually from 4.5% to 38.3%, from 5.4% to 43.4%, and from 8.7% to 49.5%, respectively (P < .001). Improved adherence was sustained among visitors and clinical staff (P < .001), but not among nonclinical staff (P = .341). The electronic motion sensor-triggered audible reminder immediately and significantly improved and sustained greater adherence of hospital visitors and clinical staff to hand hygiene guidelines. This is an effective addition to multimodal hand hygiene interventions and may help control epidemic infections.

Helping hands: A cluster randomised trial to evaluate the effectiveness of two different strategies for promoting hand hygiene in hospital nurses

BackgroundHand hygiene prescriptions are the most important measure in the prevention of hospital-acquired infections. Yet, compliance rates are generally below 50% of all opportunities for hand hygiene. This study aims at evaluating the short- and long-term effects of two different strategies for promoting hand hygiene in hospital nurses.Methods/designThis study is a cluster randomised controlled trial with inpatient wards as the unit of randomisation. Guidelines for hand hygiene will be implemented in this study. Two strategies will be used to improve the adherence to guidelines for hand hygiene. The state-of-the-art strategy is derived from the literature and includes education, reminders, feedback, and targeting adequate products and facilities. The extended strategy also contains activities aimed at influencing social influence in groups and enhancing leadership. The unique contribution of the extended strategy is built upon relevant behavioural science theories. The extended strategy includes all elements of the state-of-the-art strategy supplemented with gaining active commitment and initiative of ward management, modelling by informal leaders at the ward, and setting norms and targets within the team. Data will be collected at four points in time, with six-month intervals. An average of 3,000 opportunities for hand hygiene in approximately 900 nurses will be observed at each time point.DiscussionPerforming and evaluating an implementation strategy that also targets the social context of teams may considerably add to the general body of knowledge in this field. Results from our study will allow us to draw conclusions on the effects of different strategies for the implementation of hand hygiene guidelines, and based on these results we will be able to define a preferred implementation strategy for hospital based nursing.Trial registrationThe study is registered as a Clinical Trial in ClinicalTrials.gov, dossier number: NCT00548015.

Back to basics: practice guidelines for correct hand hygiene

Hands play a main role in the transmission of infection. To prevent infections, all health professionals need to understand the importance of hand hygiene. Renal patients are particularly susceptible to health care associated infections, so everyone coming into contact with these vulnerable patients needs to be able to perform the relevant hand hygiene procedures correctly. This is Karen Jenkins' overview.

A comparison of the hand hygiene knowledge, beliefs and practices of Italian nursing and medical students

This paper reports a study examining the hand hygiene knowledge, beliefs and practices of Italian nursing and medical students with the aim of informing undergraduate curricula. In comparison with registered nurses, physician status is a risk factor for non-compliance with hand hygiene guidelines. Little research has been conducted to determine if differences between the professions in relation to hand hygiene are apparent at the undergraduate level. Cross-disciplinary studies that may provide an insight into this topic are lacking. A questionnaire was administered to a convenience sample of 117 nursing and 119 medical students in a large university in Rome, Italy, to determine their hand hygiene knowledge, beliefs and practices. The data were collected in 2007-2008. Nursing students' hand hygiene knowledge (F = 9·03(1,230); P = 0·003), percentage compliance (Z = 6·197; P < 0·001) and self-reported hand hygiene practices (F = 34·54(1,230); P < 0·001) were significantly higher than that of medical students. There were no statistically significant differences between hand hygiene beliefs. Mean scores on the knowledge questions were low for both groups, reflecting primarily a knowledge deficit in relation to the use of alcohol-based hand rubs to decontaminate hands in the healthcare setting. Statistically significant disciplinary differences in hand hygiene knowledge and self-reported practices were apparent among undergraduate Italian healthcare students. Further research is needed to determine the causative factors. The overall low scores on the knowledge items indicate that these students require further education on hand hygiene, particularly in relation to the use of alcohol-based hand rubs.

Improvement in hand hygiene compliance. The impact of a regional strategy

Health-care workers (HCWs) adherence to hand hygiene (HH) guidelines is usually low. According to WHO recommendations, the key strategy components to improve the compliance is evaluation and feed-back.In this study we monitored HH compliance of HCWs by direct observation in Madrid and to asses the impact of an interventional strategy.

Surveying awareness of hand hygiene guidelines in the Sanin region of Japan

Given the history of the 2002 CDC guidelines usage in Japan, we surveyed the awareness and adoption of WHO Guideline on Hand Hygiene in Health Care published in 2009, particularly the Five Moments of Hand Hygiene tool by healthcare workers (HCWs) in Japan.

Practically speaking: Rethinking hand hygiene improvement programs in health care settings

Hand hygiene is widely recognized as the single most effective means of reducing health care-associated infections. Implementing a credible hand hygiene program and maintaining high compliance among staff is both expected and required of hospitals. However, beyond general guidelines, few resources are available for establishing an institution-wide hand hygiene program that is both successful and sustainable over the long term. Beginning in 2008, we completely overhauled the approach to hand hygiene at our institution. We created small teams consisting of a representative from Quality Assessment, an Infection Prevention Practitioner, and staff from a particular unit. Teams began by discussing the current barriers to hand hygiene success. They then set their own goals for hand hygiene compliance. Staff learned the World Health Organization (WHO) hand hygiene guidelines, which recently had been adopted as part of hospital infection prevention policy. Using the WHO guidelines, teams diagrammed detailed workflows for several of their most common patient care tasks. Wherever hand hygiene was indicated, the workflow was marked with a number corresponding to one or more of the WHO's "5 moments for hand hygiene." At the end of the 12-week period, staff members were trained to observe each other and began officially collecting and submitting data to Infection Prevention. Between 2006 and 2008, our average institutional hand hygiene compliance held steady at 60%-70%. After the new program was launched in 2008, compliance reached 97% and has been maintained at this level ever since. In addition to the 19 areas of the hospital that were observed previously, 15 ambulatory facilities and 5 regional sites are now included in the data. This article describes a novel approach to measuring, monitoring, and ultimately increasing hand hygiene compliance at our hospital. Our objective is to provide concrete, practical strategies for other institutions faced with the challenge of building or revamping their own hand hygiene programs.

A Multicenter Trend Analysis of Hand Hygiene Event Rates in USA Pre- and Post Joint Commission and World Health Organization Guidelines

In 2009, the Joint Commission released Measuring Hand Hygiene Adherence: Overcoming the Challenges and the World Health Organization released the Guidelines on Hand Hygiene in Healthcare. These, in addition to the 2002 Centers for Disease Control's Guideline for Hand Hygiene in Health-Care Settings, offer recommendations for product use, education, and measurement for the purpose of sustaining compliance. McGuckin Methods International manages a national hand hygiene database, with several hundred healthcare centers submitting data monthly on measurement.

Hand Hygiene Compliance and Device-Related Infection Rates in a Respiratory Intensive Care Unit

Healthcare-acquired infections (HAIs) affect 5% to 10% of all hospitalized patients and are the most common cause of preventable morbidity and mortality facing healthcare today. It is estimated that 30% of HAIs are avoidable with healthcare provider adherence to hand hygiene (HH) guidelines. Device-related HAIs are considered the principal threat to patients in the ICU, and are among the main causes of patient morbidity and mortality. We studied the impact of an educational program on HH compliance and its possible effect on device-related infection rates in a respiratory intensive care unit (RICU) in a developing country.

Hand Hygiene Practices among Nursing Staff in Public Secondary Care Hospitals in Kuwait: Self-Report and Direct Observation

Objective: To assess the compliance with hand hygiene guidelines among nursing staff in secondary care hospitals in Kuwait. Subjects and Methods: A cross-sectional study was conducted through direct observation using the Lewisham observation tool and self-administered questionnaire in six major public secondary care hospitals in Kuwait. Only patient care activities that are described as ‘dirty contacts’ by the Fulkerson scale were considered as indications for hand hygiene while any attempt for hand hygiene was considered as compliance. A self-administered questionnaire was prepared and pilot tested and then distributed to nursing staff at each ward immediately after conducting the inspection; 550 were distributed and 454 were completed and returned. Among 204 observation sessions, a total of 935 opportunities and 312 hand hygiene practices were recorded. Results: The overall compliance was 33.4%. The observed compliance significantly varied between different ward categories from 14.7% in emergency to 55% in medical wards. Of the 454 nursing staff who participated in self-reported compliance, 409 (90%) indicated that they always washed their hands upon practicing patient care activities. Nurses consistently reported higher compliance after conducting patient care activities rather than before. Being busy with work (42.2%), having sore/dry hands (30.4%) and wearing gloves (20.3%) were the most frequently reported hindrances to improving hand hygiene. Conclusion: Observed hand hygiene compliance among nursing staff in secondary care hospitals in Kuwait was poor. High self-reported compliance may reflect a high level of awareness of hand hygiene but may also suggest that improving compliance through increasing awareness has probably reached saturation.

Ethanol in pre-surgical hand rubs: concentration and duration of application for achieving European Norm EN 12791

In Europe, ethanol is a common active agent in hand rub formulations and nowadays it is also recommended in guidelines for hand hygiene published by the Centers for Disease Control and Prevention and by the World Health Organization. However, data on the range of concentrations and durations of application providing a basis for passing the efficacy test of the European norm EN 12791 are still lacking. Therefore, the bactericidal efficacy of rubbing clean hands with pure ethanol in volume concentrations of 95%, 85% or 75% during 3 min was compared with that of the reference procedure of EN 12791 employing n-propanol 60% v/v for 3 min, immediately and 3h after disinfection. Ethanol 85% was also tested at a 5 min application. A Latin-square design was used with 20 randomly allotted volunteers. Whereas the mean immediate bacterial reductions caused by ethanol at concentrations of 75% (log RF 1.68) and 95% (log RF 2.70) were significantly less efficacious compared to that of the reference (log RF 3.27), at 85% they were not significantly less active with both applications, 3 and 5 min (log RFs 2.90 and 3.12, respectively). Three hours after antisepsis, the bacterial reduction on the gloved hand was only significantly less efficacious than that of the reference when 75% ethanol was used. It is concluded that ethanol-based hand rubs have a good chance of meeting the EN 12791 requirements if their ethanol concentration is >75% v/v but <95% v/v and if they are applied for at least 3 min.

Hand Hygiene and the Surgical Team

Health care–associated infections (HAIs) are a major cause of morbidity and mortality in health care institutions in the United States and throughout the world. These infections are associated with all aspects of health care delivery, from ambulatory care procedures to hospital admission and from general wards to intensive care units and long-term care facilities. HAIs are also associated with procedures performed in the perioperative setting from insertion of invasive devices and minimally invasive diagnostic and treatment modalities to surgical intervention and follow-up care and treatment. Such infections include urinary tract infections (UTIs), surgical site infections (SSIs), pneumonia (lung infections), and bloodstream infections. A recent report from the Centers for Disease Control and Prevention estimated the annual medical costs of treating HAIs in US hospitals to be between $28 billion and $45 billion, adjusted to 2007 dollars. 1 The potential for the transmission of multidrug-resistant organisms (MDROs), including methicillin-resistant Staphylococcus aureus; vancomycin-resistant strains of Enterococci; certain gram-negative bacteria, including those producing extended-spectrum b-lactamases; and Clostridium difficile, that are associated with higher morbidity and mortality, higher cost of treatment, and longer lengths of hospital stay than infections caused by other drug-sensitive organisms is increasing because these MDROs are becoming more and more prevalent in health care institutions and the society. 2 HAIs account for an estimated 1.7 million infections and 99,000 associated deaths each year, with 32% UTIs, 22% SSIs, 15% pneumonia, and 14% bloodstream infections. 3 Hand hygiene, simply washing the hands with soap and water or using an alcohol-based waterless product if the hands are not visibly soiled, is universally thought to be the single most important procedure health care personnel can perform to prevent the transmission of HAIs. 4 However, the observed compliance rate in health care facilities has been regarded as unacceptably poor by public health authorities. 5 A recent review of compliance with hand hygiene in health care facilities concluded that noncompliance with hand hygiene guidelines is a universal problem; the overall

Heightening Residents' Awareness of Hand Hygiene Guidelines

As educators who focus on assessing the skills of incoming postgraduate year-1 residents to our institution, we were thrilled to see the recent article by Gluck et al1 assessing hand hygiene (HH) compliance. We, too, have recognized the importance of this formative time for our future leaders in medicine and have thus implemented an assessment of HH in our orientation assessment. We have briefly summarized our experience, which corroborates the findings of Gluck et al. Explicitly for the past 2 years, we have assessed both aseptic technique (AT) and hand washing on 1 station of an 11-station orientation assessment. The hand washing quiz was created based on Centers for Disease Control and Prevention guidelines.2 The quiz included questions about HH agents' effectiveness against viruses and bacteria, the length of time necessary to wash hands with soap and water, and dermatitis prevention. On completion of the AT station (where AT for bedside procedures is assessed3) the interns take an online quiz, followed by verbal feedback about general HH technique in accordance to an assessment checklist and institution protocol. Written handouts and reference materials documenting proper HH protocols are distributed on station completion for review and remediation. The findings from our application of the hand washing quiz showed that 99% of residents correctly identified the importance of hand washing in the prevention of infection and patient contact. However, less than half correctly identified the specificity of agents and methods when it came to actual practices. For example, only 49% knew alcohol gel was the best method for killing bacteria, and when asked which HH agent was least drying to skin and preserves integrity, 29% chose plain soap and water, 7% selected antimicrobial soap and water, and only 64% selected alcohol gel. Findings from the AT portion of the station, which involved an HH demonstration, resulted in a meager 23% achieving a “Done” completion rating overall on duration of washing with soap and water. Even more inferior was the postgraduate year-1 residents' demonstration of HH on completion of an aseptic procedure, achieving a low 18%, increasing the likelihood of potential transmission of hospital-acquired infections.4 The study by Gluck et al demonstrated that recent medical school graduates do not incorporate sufficient HH compliance into their routine behavior. We have also concluded from our orientation assessment a need to identify HH deficits and believe that early graduate medical education provides the ideal platform for the early identification and intervention of HH deficits.

Effects of the MicrodineTM Protocol on Facility Acquired Clostridium difficile Infections and Employee Absenteeism: 2010 Presidential Poster

Purpose: This study was designed to evaluate the efficacy and clinical acceptance of a hand hygiene protocol using MicrodineTM, a new hand sanitizer. The outcomes assessed were the effects of the MicrodineTM protocol on the rate of facility acquired Clostridium difficile (C. diff) and MRSA infections, employee absentee rates and employee acceptance of the protocol. Methods: Employees of the long-term care facility were provided a single 15 minute in-service to educate them and to demonstrate the application of MicrodineTM. They were instructed to apply MicrodineTM at the beginning of their shifts, every six hours while at work and before they left the facility at the end of their shifts (the MicrodineTM Protocol). They followed the same CDC guidelines for hand hygiene between applications of MicrodineTM as they had been following prior to the introduction of the MicrodineTM Protocol. The rates of facility acquired Clostridium difficile and MRSA during the 4 month study interval were compared to historical records of C. diff. and MRSA infections from the 7 months preceding the study for which records were made available. The effect of the MicrodineTM Protocol on employee absenteeism was evaluated by comparing the rates during this 4 month trial to the historical rates from the same 4 month intervals in the two preceding years. No other hygienic interventions or procedural changes ocurred during the study interval. Clinical acceptance of the protocol was assessed by administering a hand hygiene questionnaire to the employees after the conclusion of the study interval. Results: There was a 92% reduction in facility acquired C. diff after the MicrodineTM Protocol was initiated. This was highly statistically significant - p < .001. The effect on MRSA could not be evaluated due to rare occurrences of this infection. Employee absenteeism decreased by 45% after the MicrodineTM Protocol was initiated. This was also highly statistically significant - p < .004. The MicrodineTM Protocol also created substantial direct and indirect cost savings for the facility in excess of $55,000 during the 4 month study interval which represented a return on investment of at least 275:1. The employees' responses to the hand hygiene questionnaire revealed both clinical acceptance of the protocol and subjective improvement in hand skin health. Conclusion: The addition of the MicrodineTM Protocol to a facility's existing hand hygiene program is a highly effective and cost saving strategy to reduce facility acquired C. diff infections and employee absenteeism. Additionally, it is acceptable to the employees and produces hand skin health benefits. Disclosure: Dr McDyer is a shareholder in DRSS Global, LLC, manufacturer of Microdine. Dr Hosler is a Board Member and a shareholder in DRSS Gobal, LLC, manufacturer of Microdine.

Educating healthcare workers to optimal hand hygiene practices: addressing the need

The education of healthcare workers is essential to improve practices and is an integral part of hand hygiene promotional strategies. According to the evidence reviewed here, healthcare worker education has a positive impact on improving hand hygiene and reducing healthcare-associated infection. Detailed practical guidance on steps for the organization of education programmes in healthcare facilities and teaching-learning strategies are provided using the World Health Organization (WHO) Guidelines for Hand Hygiene in Health Care as the basis for recommendations. Several key elements for a successful educational programme are also identified. A particular emphasis is placed on concepts included in the tools developed by WHO for education, monitoring and performance feedback.

The impact of workload on hygiene compliance in nursing

The objective of this research was to clarify whether external factors (e.g. ward capacity, level of nursing intensity) had an influence on nursing staff compliance with hand hygiene guidelines. The study was conducted at a German hospital (450 beds). Quantitative data were collected prospectively in six trial phases (E1-E6) starting in June2007 and ending in May 2008. Included in the study were ten hospital departments: four surgical wards, four internal medicine departments, and two interdisciplinary intensive care units. In six participant observation trials, nursing staff were monitored for the disinfection of hands. Narrative interviews were conducted immediately after the observation with those who did not disinfect their hands in accordance with national guidelines. Observations and interviews were unannounced, taking place at different times. The collected data was analysed on subsequent categorization after summarizing the core statements (content analysis). The statistical relevance of staff compliance to the rate of used ward capacity could be proved using a multifactorial regression model (P=0.011). Workload factors (e.g. maximum ward capacity, severity of patient cases) have an impact on staff compliance with hand hygiene guidelines, even where non-compliance contradicts the personal level of professional training.

Hand hygiene in the intensive care unit

Healthcare-associated infections affect 1.4 million patients at any time worldwide, as estimated by the World Health Organization. In intensive care units, the burden of healthcare-associated infections is greatly increased, causing additional morbidity and mortality. Multidrug-resistant pathogens are commonly involved in such infections and render effective treatment challenging. Proper hand hygiene is the single most important, simplest, and least expensive means of preventing healthcare-associated infections. In addition, it is equally important to stop transmission of multidrug-resistant pathogens. According to the Centers for Disease Control and Prevention and World Health Organization guidelines on hand hygiene in health care, alcohol-based handrub should be used as the preferred means for routine hand antisepsis. Alcohols have excellent in vitro activity against Gram-positive and Gram-negative bacteria, including multidrug-resistant pathogens, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, Mycobacterium tuberculosis, a variety of fungi, and most viruses. Some pathogens, however, such as Clostridium difficile, Bacillus anthracis, and noroviruses, may require special hand hygiene measures. Failure to provide user friendliness of hand hygiene equipment and shortage of staff are predictors for noncompliance, especially in the intensive care unit setting. Therefore, practical approaches to promote hand hygiene in the intensive care unit include provision of a minimal number of handrub dispensers per bed, monitoring of compliance, and choice of the most attractive product. Lack of knowledge of guidelines for hand hygiene, lack of recognition of hand hygiene opportunities during patient care, and lack of awareness of the risk of cross-transmission of pathogens are barriers to good hand hygiene practices. Multidisciplinary programs to promote increased use of alcoholic handrub lead to an increased compliance of healthcare workers with the recommended hand hygiene practices and a reduced prevalence of nosocomial infections.

Improving hand hygiene behaviour of nurses using action planning: a pilot study in the intensive care unit and surgical ward

Compliance with hand hygiene guidelines by hospital physicians and nurses is universally low and there is a need to apply powerful intervention methods from social sciences in order to improve compliance. One method is the formation of implementation intentions (or action planning) in which concrete 'if then' plans are formulated to link an environmental cue with performance of an intended behavioural action. This pilot study explored the practicality and effects of action planning on the hand hygiene behaviour (HHB) of nurses in an ICU and surgical ward of a university teaching hospital. A pre-post test design was used, and 17 nurses were invited to participate. A trained researcher observed HHB of nurses before and three weeks after the intervention in which action plans were formulated. Frequencies were calculated and logistic regression analysis was performed to assess changes in HHB. Of the 17 participants, 10 (seven in surgical ward, three in ICU) had complete data and were included in the analyses. In total, 283 potential moments for hand hygiene were identified, 142 in the surgical ward and 141 in the ICU. HHB increased from 9.3% at baseline to 25.4% post intervention (odds ratio: 3.3; confidence interval: 1.7-6.5; P<0.001). Although this was a small scale study, the results show promise for the use of action planning to improve the HHB of nurses in the short term. Action planning has shown success in closing the intention-behaviour gap in other fields, and its use for improving HHB in healthcare should be further investigated.