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PubMed2001

Hand hygiene--comparison of international recommendations.

The value of hand hygiene for the prevention of cross-infection was first observed in the middle of the 19th century. Since then, which procedure is the most suitable for hand hygiene has been repeatedly discussed and several different guidelines and recommendations have been published. The aim of this review is to compare different recommendations for hand hygiene regarding technique and indication. Medline, the internet and a personal library were searched to obtain as many written recommendations as possible. In addition, a small questionnaire was sent by e-mail to 20 international colleagues. As a result, written recommendations from 10 countries could be compared. Recommended methods of hand hygiene include handwashing (washing hands with plain soap), hygienic handwash (washing hands with medicated soap) and hygienic hand-rub (use of antiseptic rubs). In most countries handwashing and hygienic handwash are the methods of choice and only in central European countries is hygienic hand-rub the preferred technique. Situations in which performance of hand hygiene is recommended are comparable. However, no single indication is recommended in all guidelines. Hand hygiene is most often recommended before performing invasive procedures and after microbial contamination. Guidelines should be clear and easy to follow for them to become standard of care. Thus, guidelines are needed that do not leave to the health care worker a decision as to whether hand hygiene is indicated.

Attitude of Health Personnel↗
PubMed2000

Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic.

OBJECTIVE: The objective of the study was to improve health care workers' compliance with hand hygiene after patient contact by use of an alcohol-based hand antiseptic. DESIGN AND METHODS: Six commercially available alcohol-based hand antiseptics were evaluated. The one most pleasing to the evaluators' hands was selected for the study. Baseline handwashing rates were assessed on 2 medical wards. Alcohol dispensers were mounted by every door on the 2 wards. An educational campaign was conducted with 4 weekly visits to these floors to remind and reinstruct staff about the use of the alcohol dispensers and to address questions. After 2 months handwashing rates were reassessed. SETTING: The study was set in a university hospital. RESULTS: The baseline handwashing rate was 60% (76/126). Physicians were most compliant (83%), followed by nurses (60%), technologists (56%), and housekeepers (36%). Two months later overall hand hygiene rates had decreased to 52% (P = .26). Nurses were most compliant (67%), followed by technologists (57%), physicians (29%), and housekeepers (25%). Physician compliance was associated with compliance by attending physicians whose example was usually followed by all other physicians on rounds. CONCLUSIONS: A brief educational campaign and installation of dispensers containing a rapidly acting hand hygiene product near hospital rooms did not affect hand hygiene compliance. The behavior of attending physicians was predictive of handwashing rates for all others in the attending's retinue. Compliance with handwashing after half of all patient contacts was a result of perfect compliance by some and total noncompliance by others being observed.

Anti-Infective Agents, Local↗
PubMed2003

Recognising the psychosocial issues involved in hand hygiene.

Non-adherence to hand hygiene among those involved in the provision of health care is the principal route by which infection is spread. However, despite an extensive research base, regular education and the application of prescriptive rules there has been a consistent failure to achieve long-term adherence in appropriate hand hygiene practice. Where improved adherence has been achieved there has been little evidence to show that it was for anything other than a limited period with individuals ultimately reverting back to their original practice. This paper therefore proposes that the principal cause of non-adherence to safe hand hygiene practice among those involved in the provision of health care is psychosocial in its nature. Further, until strategies are developed that will reflect this, the well-being of individuals seeking health care intervention will continue to be compromised.

Attitude of Health Personnel↗
PubMed2006

Behavioural considerations for hand hygiene practices: the basic building blocks.

Hand hygiene is considered to be the most effective measure to prevent microbial pathogen cross-transmission and healthcare-associated infections. In October 2005, the World Health Organization (WHO) World Alliance for Patient Safety launched the first Global Patient Safety Challenge 2005-2006, 'Clean Care is Safer Care', to tackle healthcare-associated infection on a large scale. Within the Challenge framework, international infection control experts and consultative taskforces met to develop new WHO Guidelines on Hand Hygiene in Healthcare. The taskforce was asked to explore aspects underlying hand hygiene behaviour that may influence its promotion among healthcare workers. The dynamics of behavioural change are complex and multi-faceted, but are of vital importance when designing a strategy to improve hand hygiene compliance. A reflection on challenges to be met and areas for future research are also proposed.

Attitude of Health Personnel↗
PubMed2004

Hand hygiene and aseptic technique in the emergency department.

Hand hygiene and simple aseptic measures before invasive procedures are effective in reducing rates of healthcare-associated infection. The perceived urgency of a clinical situation in the emergency department, however, may influence medical staff's compliance with good practice in infection control. The aims of this prospective, single-blinded, observational study were twofold. First, to assess doctors' compliance with good practice in hand hygiene between patient episodes and asepsis during invasive procedures in the emergency department. Second, to assess the effect of clinical urgency on compliance with good practice in hand hygiene and asepsis during invasive procedures. Good practice standards for asepsis in invasive procedures and hand hygiene between patient episodes were compiled from a literature search. Doctors' compliance with these standards was observed in two emergency departments (UK and New Zealand). Observed clinical cases were classified as immediate, urgent and non-urgent based on the triage system. There was poor compliance with good practice guidelines for asepsis in invasive procedures in both centres. Staff achieved high compliance with the guidelines in only 27% of cases in the UK and 58% of cases in New Zealand. Clinical urgency did not appear to adversely affect compliance with aseptic good practice. Hand hygiene between patient consultations was very low at 14% in the UK and 12% in New Zealand. Asepsis and hand hygiene was poor in both the UK and New Zealand emergency departments. There may be a need for some compromise in standards of asepsis in very sick patients due to the urgency of the clinical situation. Compliance in all situations especially non-urgent procedures needs to be improved.

Asepsis↗
PubMed2003

Factors associated with hand hygiene practices in two neonatal intensive care units.

OBJECTIVE: To determine whether hand hygiene practices differ between levels of contact with neonates; to characterize the hand hygiene practices of different types of personnel; and to compare hand hygiene practices in neonatal intensive care units (NICUs) using different products. METHODS: Research assistants observed staff hand hygiene practices during 38 sessions in two NICUs. Patient touches were categorized as touching within the neonates' environment but only outside the Isolette (Level 1), touching within the Isolette but not the neonate directly (Level 2) or directly touching the neonate (Level 3). Hand hygiene practices for each touch were categorized into five groups: cleaned hands and new gloves; uncleaned hands and new gloves; used gloves; clean hands and no gloves; uncleaned hands and no gloves. RESULTS: Research assistants observed 1472 touches. On average each neonate or his or her immediate environment was touched 78 times per shift. Nurses (P = 0.001), attending physicians (P = 0.02) and physicians-in-training (P = 0.03) were more likely to use appropriate practices during Level 3 touches, but only 22.8% of all touches were with cleaned and/or newly gloved hands. The mean number of direct touches by staff members with cleaned hands was greater in the NICU using an alcohol-based hand rub than in the NICU using antimicrobial soap (P < 0.01). CONCLUSIONS: Hand hygiene was suboptimal in this high risk setting; administrative action and improved products may be needed to assure acceptable practice. In this study use of an alcohol-based product was associated with significantly improved hand hygiene and should be encouraged, as recommended in the new CDC hand hygiene guideline.

Analysis of Variance↗
PubMed2004

Hand hygiene among physicians: performance, beliefs, and perceptions.

BACKGROUND: Physician adherence to hand hygiene remains low in most hospitals. OBJECTIVES: To identify risk factors for nonadherence and assess beliefs and perceptions associated with hand hygiene among physicians. DESIGN: Cross-sectional survey of physician practices, beliefs, and attitudes toward hand hygiene. SETTING: Large university hospital. PARTICIPANTS: 163 physicians. MEASUREMENTS: Individual observation of physician hand hygiene practices during routine patient care with documentation of relevant risk factors; self-report questionnaire to measure beliefs and perceptions. Logistic regression identified variables independently associated with adherence. RESULTS: Adherence averaged 57% and varied markedly across medical specialties. In multivariate analysis, adherence was associated with the awareness of being observed, the belief of being a role model for other colleagues, a positive attitude toward hand hygiene after patient contact, and easy access to hand-rub solution. Conversely, high workload, activities associated with a high risk for cross-transmission, and certain technical medical specialties (surgery, anesthesiology, emergency medicine, and intensive care medicine) were risk factors for nonadherence. LIMITATIONS: Direct observation of physicians may have influenced both adherence to hand hygiene and responses to the self-report questionnaire. Generalizability of study results requires additional testing in other health care settings and physician populations. CONCLUSION: Physician adherence to hand hygiene is associated with work and system constraints, as well as knowledge and cognitive factors. At the individual level, strengthening a positive attitude toward hand hygiene and reinforcing the conviction that each individual can influence the group behavior may improve adherence among physicians. Physicians who work in technical specialties should also be targeted for improvement.

Adult↗
PubMed2006

Improving adherence to hand hygiene among health care workers.

Increased adherence to hand hygiene is widely acknowledged to be the most important way of reducing infections in health care facilities. Despite evidence of benefit, adherence to hand hygiene among health care professionals remains low. Several behavioral and organizational theories have been proposed to explain this. As a whole, the success of interventions to improve adherence to hand hygiene among health care professionals has been limited. Recent data suggest that a multifaceted intervention, including the use of feedback, education, the introduction of alcohol-based hand wash, and visual reminders, may increase adherence to hand-hygiene recommendations. Although the "active ingredient" of such an intervention is unknown, there is evidence that the use of feedback may be the key to increasing adherence. In this article, we review the theoretical basis for interventions and provide an overview of the evidence for interventions. Coherent and methodologically sound research is required to better understand the factors contributing to hand-hygiene behavior among health care professionals.

Allied Health Personnel↗
PubMed2004

Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission?

Improvement in hand hygiene compliance is important for reducing cross-infection by micro-organisms. The objective of this prospective observational study was to measure how the improper use of gloves limits compliance to hand hygiene and exposes patient's to infection. The study was conducted in five wards (three intensive care units and two medical wards) in a French university hospital. Staff-patient and staff-environment contacts were observed in 120 healthcare workers caring for patients colonized or infected with pathogenic bacteria. Hand hygiene was not undertaken due to improper gloving in 64.4% (95%CI, 64.1% to 65.1%) of instances. Possible microbial transmission might have occurred in 18.3% (95%CI, 17.8% to 18.8%) of all contacts because used gloves were not removed before performing care activities that necessitated strict aseptic precautions. Failure to change or remove contaminated gloves was a major component in the poor compliance with hand hygiene and carried a high-risk of microbial transmission. Improving hand hygiene compliance will require changing healthcare workers behaviour towards glove use.

Anti-Infective Agents, Local↗
PubMed2000

Skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water hand washing versus hand antisepsis with an alcoholic hand gel.

OBJECTIVE: To compare the frequency of skin irritation and dryness associated with using an alcoholic-hand-gel regimen for hand antisepsis versus using soap and water for hand washing. DESIGN: Prospective randomized trial with crossover design. Irritation and dryness of nurses' hands were evaluated by self-assessment and by visual assessment by a study nurse. Epidermal water content of the dorsal surface of nurses' hands was estimated by measuring electrical capacitance of the skin. SETTING: Miriam Hospital, a 200-bed university-affiliated teaching hospital. PARTICIPANTS: Thirty-two nurses working on three hospital wards participated in the trial, which lasted 6 weeks. RESULTS: Self-assessment scores of skin irritation and dryness decreased slightly during the 2 weeks when nurses used the alcoholic-hand-gel regimen (mean baseline score, 2.72; mean final score, 2.0; P=.08) but increased substantially during the 2 weeks when nurses used soap and water (mean baseline score, 2.0; mean final score, 4.8; P<.0001). Visual assessment scores by the study nurse of skin irritation and dryness did not change significantly when the alcoholic-hand-gel regimen was used (mean baseline and final scores were both 0.55), but scores increased substantially when nurses used soap and water (baseline score, 0.59; mean final score, 1.21; P=.05). Epidermal water content of the dorsal surface of nurses' hands changed little when the alcoholic-hand-gel regimen was used (mean+/-standard deviation baseline electrical capacitance reading, 24.8+/-6.8; mean final reading, 25.7+/-7.3), but decreased significantly (skin became dryer) with soap-and-water hand washing (mean baseline, 25.9+/-7.5; mean final reading, 20.5+/-5.4; P=.0003). CONCLUSIONS: Hand antisepsis with an alcoholic-hand-gel regimen was well tolerated and did not result in skin irritation and dryness of nurses' hands. In contrast, skin irritation and dryness increased significantly when nurses washed their hands with the unmedicated soap product available in the hospital. Newer alcoholic hand gels that are tolerated better than soap may be more acceptable to staff and may lead to improved hand-hygiene practices.

Antisepsis↗
PubMed2005

Cross-sectional survey of hand-hygiene compliance and attitudes of health care workers and visitors in the intensive care units at King Chulalongkorn Memorial Hospital.

BACKGROUND: Hand hygiene is the most important and effective measure to prevent cross-infection in hospitals. Hand-hygiene campaign must be implemented as a part of infection control program at King Chulalongkorn Memorial Hospital (KCMH). The behavior attitudes, and beliefs of health care workers (HCWs) and visitors regarding hand-hygiene practices have never been studied in KCMH. OBJECTIVES: To determine the baseline compliance and assess the attitudes and beliefs regarding hand hygiene of HCWs and visitors in intensive care units (ICUs) at KCMH. MATERIAL AND METHOD: We observed hand-hygiene compliance of HCWs and visitors in ICUs before patient contact for eight hours. A self-administered questionnaire was employed to measure attitudes and beliefs about hand hygiene for two-week period. RESULTS: Overall hand-hygiene compliance obtained from this observational study was less than 50% and differed markedly among various professional categories of HCWs and visitors. In questionnaire-based study, patient needs perceived as a priority (51.2%) was the most common reason for non-compliance, followed by forgetfulness (35.7%), and skin irritation by hand-hygiene agents (15.5%). Subjects believed to improve their compliance by multiple strategies including available low irritating hand-hygiene agents (53.4%), information of current nosocomial infection rate (49.1%), and easily accessed hand-hygiene supplies (46.3%). Almost all subjects (99.7%) claimed to know correct hand-hygiene techniques. Handwashing with medicated soap was perceived to be the best mean of hand decontamination (37.8%). CONCLUSION: Hand-hygiene compliance of HCWs and visitors is unacceptably low. Their knowledge, behavior attitudes, and beliefs toward hand hygiene need to be improved by the multimodal and multidisciplinary approach.

Attitude of Health Personnel↗
PubMedDate not supplied

The effectiveness of alcohol based hand rubs and compliance with hand hygiene.

Pittet et al.'s (2000) study observed that an increase in compliance with hand hygiene, especially alcohol based hand rubs, was related to a decrease in the rate of nosocomial infections. The results of this study can be used in a group utilization project of providing information on efficacy and compliance issues related to hand hygiene. All HCWs, but most importantly nurses, can recommend hand hygiene programs on specific units to ensure client health and reduce unwanted health care cost. Feasibility issues would include teaching correct hand hygiene technique and compliance for new hospital employees and costs of educational materials. Considerations would be the length of program, location, and implementation strategies. Future research might focus on the use of a smaller sample size, where more control can be obtained, and the use of different hand hygiene techniques in the prevention of nosocomial infections.

Comment↗
PubMedDate not supplied

Improving hand hygiene compliance.

Achieving compliance with hand hygiene can be difficult. Annette Jeanes explains how a new approach to marketing hand hygiene produced sustained positive results.

Anti-Infective Agents, Local↗
PubMedDate not supplied

Innovations in hand hygiene: Manugel from SSL International.

Hand hygiene is the single most effective method of preventing cross-infection. Barriers to performing effective hand hygiene include lack of time and the poor cosmetic acceptability of many of the available hand decontaminants. These problems are exacerbated in domiciliary nursing care where conditions in some homes may prevent adequate decontamination, especially when drying hands. Damp hands transfer bacteria more effectively than dry ones. The availability of newer alcoholic hand gels is helping to overcome these problems and the introduction of single-use sachets is of particular benefit in domiciliary care.

2-Propanol↗
PubMed2005

Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina.

BACKGROUND: Hand hygiene is a fundamental measure for the control of nosocomial infection. However, sustained compliance with hand hygiene in health care workers is poor. We attempted to enhance compliance with hand hygiene by implementing education, training, and performance feedback. We measured nosocomial infections in parallel. METHODS: We monitored the overall compliance with hand hygiene during routine patient care in intensive care units (ICUs); 1 medical surgical ICU and 1 coronary ICU, of 1 hospital in Buenos Aires, Argentina, before and during implementation of a hand hygiene education, training, and performance feedback program. Observational surveys were done twice a week from September 2000 to May 2002. Nosocomial infections in the ICUs were identified using the National Nosocomial Infections Surveillance (NNIS) criteria, with prospective surveillance. RESULTS: We observed 4347 opportunities for hand hygiene in both ICUs. Compliance improved progressively (handwashing adherence, 23.1% (268/1160) to 64.5% (2056/3187) (RR, 2.79; 95% CI: 2.46-3.17; P < .0001). During the same period, overall nosocomial infection in both ICUs decreased from 47.55 per 1000 patient-days (104/2187) to 27.93 per 1000 patient days (207/7409) RR, 0.59; 95% CI: 0.46-0.74, P < .0001). CONCLUSION: A program consisting of focused education and frequent performance feedback produced a sustained improvement in compliance with hand hygiene, coinciding with a reduction in nosocomial infection rates in the ICUs.

Argentina↗
PubMed2005

Hand hygiene behavior in a pediatric emergency department and a pediatric intensive care unit: comparison of use of 2 dispenser systems.

BACKGROUND: Adherence to hand hygiene standards is poor. Approaches and systems to improve hand hygiene practices warrant testing. OBJECTIVE: To compare the frequency of use of manually operated and touch-free dispensers of sanitizer for hand hygiene. METHODS: Manual and touch-free dispensers of alcohol sanitizer were placed in the emergency department and an intensive care unit of a large pediatric hospital for two 2-month periods for each type of dispenser. Counting devices installed in each dispenser and direct observations were used to determine actual frequency of and indications for hand hygiene. RESULTS: The touch-free dispensers were used significantly more often than were the manual dispensers. The means for the number of episodes of hand hygiene per hour were 4.42 for the touch-free dispensers and 3.33 for the manual dispensers (P=.04); the means for the number of episodes per patient per hour were 2.22 and 1.79, respectively (P=.004); and the means for the number of uses of the dispenser per day were 41.2 and 25.6, respectively (P=.02). However, the overall compliance rate was 38.4% (2136 episodes of hand hygiene per 5568 indications for hand hygiene). CONCLUSIONS: The type of dispensing system influenced hand hygiene behavior. Nevertheless, overall hand hygiene compliance remained low. In order for interventions to have a major effect on hand hygiene, multiple factors must be considered.

Education, Continuing↗