Hand hygiene improvements

How does hand hygiene impact infection control?

Hand hygiene is considered as the primary measure to prevent healthcare-associated infection because healthcare workers’ hands are the most common route of transmission for microorganisms during care delivery. Hand hygiene is part of standard and isolation precautions and at the core of multifaceted strategies to prevent specific types of infection (e.g., surgical site, vascular catheter- and urinary catheter-related infections, and ventilator-associated pneumonia).

What elements of hand hygiene are necessary for infection prevention and control?

The key principles for hand hygiene best practices in order to prevent microbial transmission during health care are:

Hand hygiene should be performed at the appropriate time and using the correct technique.
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There are five key moments when hand hygiene needs to be performed to significantly reduce the risk of pathogen transmission:

1) before touching a patient

2) before clean/aseptic procedures

3) after body fluid exposure/risk

4) after touching a patient and

5) after touching patient surroundings (Figure 1. Courtesy of Sax H et al. J Hosp Infect. 2007.)

Hand hygiene can be performed either by washing with soap and water or by rubbing with an alcohol-based handrub formulation. Of note, the latter should be used as the preferred means for routine hand hygiene in health care and every possible effort should be made to procure alcohol-based handrubs for use at the point of care.
Efficacious hand antisepsis during routine care requires approximately 20-30 seconds for handrubbing with an alcohol-based formulation and about 40-60 seconds for hand washing with soap and water. For both techniques, specific rubbing movements are required to achieve complete coverage of hand surfaces (Figure 2).
To achieve hand hygiene improvement at the bedside in a healthcare facility, the strategy should include several intervention levels and thus be multimodal. Essential elements are:

1) system change, i.e., procurement of alcohol-based handrubs at the point of care

2) healthcare workers’ education

3) monitoring of hand hygiene compliance and other indicators, and performance feedback to healthcare workers and decision makers

4) use of reminders in the workplace and

5) improvement of the institutional safety climate, including commitment by senior managers and patient participation.

What are the conclusions of available clinical trials or meta-analyses regarding hand hygiene that guide infection control practices and policies?

Healthcare workers have the perception that their compliance with hand hygiene recommendations is high, usually above 80%. In contrast, many studies demonstrate that hand hygiene compliance is usually very low, on average lower than 40%.
To be successful, interventions aimed at improving hand hygiene practices should be multimodal and based on the key elements listed in section 2 (Table I). The most frequently reported indicators of success are increased hand hygiene compliance rates, improved perception of the importance of hand transmission and hygiene and improved knowledge of hand hygiene recommendations among healthcare workers, and increased consumption of alcohol-based handrubs.
Compared to other hand hygiene agents, alcohol-based handrubs have the broadest antimicrobial spectrum, better skin tolerability, and require a shorter time for effective antimicrobial decontamination. In addition, they can be made immediately available at the point of care more easily than soap and water. Handwashing with either plain or antimicrobial soap and water should be preferred when hands are visibly dirty or soiled with blood or other body fluids, when exposure to potential spore-forming organisms (e.g., Clostridium difficile) is strongly suspected or proven, or after using the lavatory.
Wearing gloves does not fully protect hands from being contaminated by microorganisms; regardless of glove use, hand hygiene must be performed at any time when indicated during the healthcare process and after glove removal.
Despite some differences and limitations in study methods, there is convincing evidence (Table II) that hand hygiene improvement decreases microbial transmission, including resistant pathogens, in healthcare settings, reduces the incidence of healthcare-associated infection, and critically contributes to control outbreaks.

In addition to these key conclusions, more detailed recommendations included in the World Health Organization (WHO) Guidelines on Hand Hygiene in Health Care and based on the best evidence from scientific studies published until 2008 are provided in Table III.

What are the consequences of ignoring hand hygiene?

Failure to perform appropriate hand hygiene leads to the transmission of healthcare-associated microorganisms, the spread of antimicrobial resistance, and ultimately to the occurrence of healthcare-associated infection, including outbreak situations.
Preference for, or the exclusive use of handwashing with soap and water for routine hand antisepsis leads to lower compliance with hand hygiene indications as the technique takes more time, causes more skin irritation, and requires the healthcare worker to move physically to the sink.
Failure to clean hands ultimately allows more infections to occur and may lead to subsequent morbidity, mortality, and the use of additional resources.

What other information supports the research on hand hygiene?

The following additional information supports the key conclusions:

The opinion and consensus of over 50 international infection control experts support the key conclusions and were taken fully into account during the development of the WHO hand hygiene recommendations.
The pilot test results of the WHO recommendations and multimodal hand hygiene improvement strategy in different settings around the world bring field experience and data that fully support these key conclusions.
Finally, in response to the call by the WHO First Global Patient Safety Challenge, many countries around the world have committed to tackle healthcare-associated infection through hand hygiene improvement and have initiated national campaigns based on the above key principles.

A summary of the current controversies regarding hand hygiene.

The conduct of a good quality study to demonstrate the sole effect of hand hygiene on healthcare-associated infection is very challenging because of difficulties inherent to healthcare-associated infection surveillance and the parallel implementation of other infection control measures usually in place. Many studies demonstrating the impact of hand hygiene on healthcare-associated infection are of good quality, but most have a before-after design. The need for more randomized control studies is a subject of controversy among experts as they would be difficult to conduct.
Monitoring hand hygiene system and process indicators to evaluate the effect of hand hygiene promotion is essential. Detection of hand hygiene compliance through direct observation is considered the gold standard although it is a time- and resource-consuming method. Controversy exists on the value of monitoring alcohol-based handrub consumption as a surrogate marker in place of hand hygiene compliance to evaluate the impact of hand hygiene campaigns.
Patient participation in hand hygiene promotion has been identified as a potentially successful component of improvement strategies. However, sociocultural issues limiting patient willingness to be involved, as well as potentially negative reactions by healthcare workers, render this topic controversial.
Hand hygiene improvement requires behavioral change among healthcare workers and continuous support by decision makers. Although many studies demonstrate that these requirements can be achieved, controversies still exist on how best to ensure long-term sustainability.
Limited data are available yet to evaluate the cost-effectiveness of hand hygiene campaigns and show very positive results; additional good quality studies would certainly be beneficial.
The role of hand hygiene has been questioned in some situations related to the spread of Clostridium difficile, norovirus and parasites because of the lack of efficacy of alcohol-based handrubs on these pathogens. Controversies exist on the recommendation to use handwashing in place of handrubbing.

What is the impact of improvements to hand hygiene relative to the impact of other aspects of infection control?

Essential indications for hand hygiene

Understanding the reasons for non-compliance with hand hygiene by healthcare workers is crucial to identify the best strategies to improve practices. Many studies have investigated determinants of poor hand hygiene performance both with objective methods and by assessing healthcare workers’ perceptions. Hand hygiene compliance has indeed been found to vary according to work intensity, type of ward, professional category, time of day/week, and several other factors. For instance a recent systematic review found lower unadjusted compliance rates in intensive care units (30%–40%) than in other settings (50%–60%), among physicians (32%) than among nurses (48%), and before (21%) rather than after (47%) patient contact.

Most, if not all identified factors can be addressed through specific interventions. As an example, the “high work intensity” factor, which leads to both a high number of hand hygiene opportunities and lack of time to perform it, can be overcome by providing alcohol-based handrubs at the point of care (system change) and by educating healthcare workers to focus on really essential indications for hand hygiene that apply in five moments according to the WHO approach (Figure 1).

System change: Ensuring that the necessary infrastructure and products are in place to allow hand hygiene performance at the point of care. This includes two essential elements:

1) access to a safe, continuous water supply and the availability of soap and disposable towels

2) availability of effective and well-tolerated alcohol-based handrub products at the point of care.

Training/education: Provision of regular training to all healthcare workers to heighten awareness of microbial transmission through hands, to emphasize the importance of hand hygiene and its indications, and to demonstrate the correct procedures for handrubbing and handwashing. Healthcare workers’ education can be achieved using regular presentations, e-learning modules, posters, focus groups, reflective discussion, videos, self-learning modules, practical demonstrations, feedback from assessment, buddy systems, or combinations of these and other methods. Knowledge evaluation is recommended to identify gaps and areas for continuous education.
Evaluation and feedback: Monitoring hand hygiene practices and infrastructure, together with related perceptions and knowledge among healthcare workers, while providing performance and feedback of results to staff. The gold standard for measuring hand hygiene compliance is direct observation of hand hygiene opportunities and actions; electronic monitoring of hand hygiene actions and evaluation of alcohol-based handrub consumption can also be used as indirect methods and surrogate markers.
Reminders in the workplace: Placing reminders and prompts (posters, stickers, voice prompts, leaflets, gadgets, etc.) related to the importance of hand hygiene and the appropriate indications and procedures for its performance.
Institutional safety climate: Creating an environment and a culture aware of patient safety issues with hand hygiene improvement considered a high priority at all levels including:

1) active participation in hand hygiene improvement efforts at both the institutional and individual levels

2) awareness of individual and institutional capacity to change and improve (self-efficacy); 3) partnership with patients and patient organizations (depending on cultural issues and resources available).

The effect of hand hygiene promotion strategies is demonstrated by a significant increase in hand hygiene compliance (Table I) and an improvement of other indicators. The most successful strategies combine several components and form multimodal and multidisciplinary approaches. Central to several of these components, in particular education, monitoring and feedback, are the essential indications for hand hygiene performance. Evidence- and consensus-based indications were identified within both the United States Centers for Disease Control and Prevention (CDC) and the WHO guidelines on hand hygiene (Table III).

Based on these recommendations, a group of international experts identified a new concept to summarize hand hygiene indications and to translate these into practice according to specific situations at higher risk of microbial transmission. This concept, named “My five moments for hand hygiene” (Figure 1), proposes a unified vision for healthcare workers, trainers, and observers to minimize inter-individual variation and to facilitate understanding and ease of recall when hand hygiene actions are needed at the point of care. According to this concept, healthcare workers are requested to clean their hands:

1) before touching a patient

2) before clean/aseptic procedures

3) after body fluid exposure/risk

4) after touching a patient and

5) after touching patient surroundings.

Drawn from the scientific evidence and based on pilot testing, these are the key concepts at the core of the WHO multimodal hand hygiene improvement strategy, the implementation strategy of the WHO Guidelines on Hand Hygiene in Health Care.

Impact of hand hygiene improvement on occurrence of healthcare-associated infection

A high number of hospital-based studies focusing on hand hygiene interventions and published up to December 2010 (Table III) showed a temporal relation between improved hand hygiene practices and reduced infection and cross-transmission rates. The impact was demonstrated by the decreased frequency of overall healthcare-associated infection and of specific types of infection. Many studies showed a reduction in methicillin-resistant S. aureus (MRSA) infections, bacteremia, and clinical isolates, and effectiveness to control MRSA outbreaks.

Some studies also demonstrated an impact on other specific microorganisms, such as vancomycin-resistant enterococci, Klebsiella spp, and rotavirus. In most, if not all studies, the hand hygiene improvement strategy was multimodal and included some or all the components described above. Most studies were conducted in adult and neonatal intensive care units, but in some the scope was much broader with hospital-wide extension and coverage of an entire region, state, or country. In most cases, a follow-up of less than one year was reported, however, several studies demonstrated a sustained effect for longer periods of time.

In addition to these studies specifically focused on hand hygiene interventions, hand hygiene was at the core of many studies implementing broader infection control interventions and showing an impact on healthcare-associated infection rates. Indeed, hand hygiene is a key part of specific recommendations for the prevention of the most frequent healthcare-associated infections. Furthermore, hand hygiene programs tackle so many aspects, e.g., from education and performance monitoring to care organization, engineering, and product procurement, that they inevitably integrate with other infection control strategies in addition to representing a model for these.

National strategies on infection control have hand hygiene at their core in many countries and have established clear annual targets to be achieved by healthcare facilities. For instance, the incidence of MRSA bacteremia and MRSA isolates have decreased dramatically at national level in England and France as a result.

Overview of the important clinical trials, meta-analyses, case control studies, case series, and individual case reports related to infection control and hand hygiene.

Table I: Hand hygiene compliance change after hand hygiene promotion interventions (update December 2009)

Table II: Impact of hand hygiene promotion as a unique intervention on the occurrence of healthcare-associated infection (update December 2010)

Table III: Evidence- and consensus-based recommendations from the WHO Guidelines on Hand Hygiene in Health Care 2009

Figure 1: My 5 moments for hand hygiene.

Figure 2: How to handrub? How to handwash?

Controversies in detail.

Impact of hand hygiene improvement on the incidence of healthcare-associated infections

Hand hygiene promotion is often put in place together with the reinforcement or introduction of other infection control measures. For this reason, it could be considered difficult to assess the real impact of hand hygiene as a single intervention on outcome measures and some controversy exists on this topic. However, a careful scrutiny of the available literature up to December 2010 revealed that 29 published studies evaluated this research question with no implementation of other major interventions (Table II). Only four studies failed to demonstrate a significant reduction of healthcare-associated infection. However, as a significant hand hygiene improvement was not achieved in three, infection decrease should not have been expected.

The vast majority of the 29 studies had an observational, before/after design, i.e., comparing the outcome measure before and after the intervention, and were neither randomized nor controlled. This is considered a limitation. Most studies implemented multiple components of hand hygiene promotion simultaneously as a multifaceted intervention. As the study design did not include any controls and clustering in most cases, it is not possible to assess what is the most effective component of these hand hygiene strategies.

Hand hygiene monitoring

Unobstrusive direct observation of healthcare practices by validated observers is considered the gold standard to evaluate hand hygiene compliance. This method allows the observer to detect if hand hygiene actions are performed when a real opportunity occurs, and to evaluate the type of technique used and its appropriateness; the healthcare worker’s professional category and/or identity can also be detected, if appropriate. These details are very important for a comprehensive hand hygiene improvement strategy because they allow the observer to identify gaps and can be used for staff education and performance feedback, to motivate sustained improvement, or to point out defective behavior. They are also extremely valuable for the creation of an institutional safety climate where individuals and managers become more accountable and united around the goal of improvement.

Current controversies related to this method include:

1) standardized protocols should be used, especially to enable interfacility comparison

2) healthcare workers’ performance may be influenced by the presence of the observer (Hawthorne effect)

3) direct observation is time-consuming and therefore resource costly and

4) requires specific expertise.

Regarding the first point, a standardized and validated method has been made available by WHO, together with an observation form, a manual for observers, training films, and files for data entry and analysis. This allows the observer to use the same method over time and by different facilities, and provides opportunities for benchmarking, pending validation of standardized observers’ and stringent adherence to the methodology. Although the Hawthorne effect may occur, the covert presence of the observer could raise issues of acceptance by healthcare workers and jeopardize the positive potential of showing local data to raise awareness and motivate behavioral change. Indeed, hand hygiene monitoring is closely linked to the other two strategic elements: education and performance feedback.

Monitoring hand hygiene compliance should become part of routine activities, at least at regular intervals and in high-risk settings; under these conditions, the Hawthorne effect is likely to be neutralized.

Electronic automated systems for hand hygiene compliance monitoring are now available or being tested. These can overcome some of the limitations inherent to direct observation and have several advantages: the possibility of continuous monitoring, a lower Hawthorne effect, saving in terms of human resources and the possibility of downloading and analyzing data automatically. Monitoring alcohol-based handrub consumption is a surrogate marker of hand hygiene compliance.

However, according to a systematic review of the literature recently conducted by WHO, published studies lack strong scientific evidence and reveal several limitations inherent to the technologies used. Indeed, most of these systems fail to identify standardized hand hygiene indications; they are also usually unable to identify HCWs and individual hand hygiene opportunities and actions, and to evaluate glove use or the appropriateness of the hand hygiene technique. Finally, cost-effectiveness remains unknown and suitability for use in settings with limited resources is quite unlikely. Therefore, although these new technologies are promising and could be part of the future approach to hand hygiene compliance monitoring, additional research is needed to support their adoption as a standard.

Recent publications have attributed high value to this method, mostly because it is simple, not affected by selection or observer bias, less time- and resource-consuming, and it appears to correlate with the incidence reduction of some types of healthcare-associated infections over time. However, the actual correlation between alcohol-based handrub consumption and hand hygiene compliance is controversial; some studies have demonstrated an association and others have not. However, it is crucial to point out that methods based on product consumption cannot determine if hand hygiene actions are performed at the right moment during care or if the technique is correct. Therefore, this information cannot be used for staff education and motivation. In addition this measurement may not exactly reflect product consumption by healthcare workers alone and could include amounts used by visitors or patients, especially if dispensers are wall-mounted and located in public areas.

In conclusion, although alcohol-based handrub consumption is a useful parameter to track system change, caution should be used while adopting this indicator in place of hand hygiene compliance.

Patient participation in hand hygiene promotion

Several studies have demonstrated that patient empowerment through education and posters, including their involvement in reminding healthcare workers and stimulating role models, can be a successful component of hand hygiene improvement strategies. However, this approach is still a matter of debate because of the need for more evidence regarding its implications and effectiveness, and the complexity of sociocultural issues involved. Asking healthcare workers whether they have cleaned their hands or observing their behavior is still perceived unfeasible by some patients and research groups.

In addition, it may induce counterproductive reactions among healthcare workers who may feel that their role is being undermined and raise unnecessary barriers between staff and patients. In conclusion, patient participation has a good potential as an element of hand hygiene improvement strategies, but it should be implemented when awareness about the importance of hand hygiene has been consolidated within the healthcare setting, after careful evaluation of sociocultural issues and beliefs, and include the involvement of healthcare workers in this approach. Last, but not least, patient empowerment cannot be implemented in institutions where a multimodal hand hygiene promotion strategy is not already in place and rolling.

Long-term sustainability

Long-term sustainment of hand hygiene improvement requires all key elements of multimodal strategies to be continuously implemented and refreshed, and real behavioral change by healthcare workers. So far, few published studies have demonstrated long-term (≥ 2 years) impact and sustainability of hand hygiene campaigns, including cost-effectiveness. In addition, the best approaches and leverage to achieve long-term sustainability need to be identified more clearly through good quality studies. For instance, controversies still exist about the positive effect of financial incentives to healthcare workers, or of reproaches and sanctions for exemplary or bad hand hygiene performance.

Continuous availability of alcohol-based handrubs, regular monitoring and feedback of hand hygiene compliance, education at the bedside, and ownership of hand hygiene projects at ward level, are success factors for long-term sustainability.

Hand hygiene and C. difficile, norovirus and parasites

Similar to all other antiseptic agents used for hand hygiene, alcohol-based handrubs have no antimicrobial efficacy against bacterial spores and protozoan oocysts, and somewhat reduced efficacy against noroviruses. For this reason, there is controversy regarding the widespread use of alcohol-based handrubs according to international recommendations and the potential impact on the spread of these pathogens. For norovirus, in vitro virucidal activity against surrogate strains of norovirus was demonstrated by 70% alcohol-based formulations and some norovirus outbreaks were controlled with various preventive measures, including handrubbing with alcohol-based formulations. The only effective measure for hand decontamination from C. difficile spores and parasite oocysts is the mechanical elimination through rubbing with soap and rinsing with water; for this reason, handwashing should be preferred when exposure to these microorganisms is strongly suspected or proven.

Based on these elements, some have raised the issue of the potential role of alcohol-based handrub implementation and the increasing trends of C. difficile incidence in some countries. However, several publications have demonstrated the lack of correlation between these events. Caution should be used when discouraging the widespread use of alcohol-based handrubs because of these arguments. Indeed, although handwashing should be preferred and maximum barrier precautions should be reinforced during C. difficile outbreaks, neglecting the value of alcohol-based handrub as the essential element to achieve hand hygiene improvement will only jeopardize overall patient safety in the long term.

What national and international guidelines exist related to hand hygiene?

The WHO Guidelines on Hand Hygiene in Health Care 2009 are the most recent and internationally referenced ones. These were inspired by the 2002 CDC Guidelines on Hand Hygiene. National guidelines exist in many countries and in most cases are based on these documents.

What other consensus group statements exist and what do key leaders advise?

The WHO Guidelines on Hand Hygiene in Health Care include input and consensus by more than 50 experts worldwide (see list of contributors) according to the best available evidence.

Disclosure

WHO takes no responsibility for the information provided or the views expressed in this paper.

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