Hand hygiene compliance

Hand hygiene is the general term for cleansing using soap, water, and other disinfecting agents. It is imperative in preventing the spread of infections. In hospitals or other health-care settings, clinical staff must follow hand hygiene guidelines before examining patients, after interaction with bodily fluids, before invasive procedures, and after medical glove removal. The US Centers for Disease Control and Prevention (CDC) has suggested that during a shift of twelve hours, some healthcare providers may need to clean their hands up to one hundred times and they have estimated that healthcare workers properly wash their hands less than fifty percent of the times that they should. According to the World Health Organization (WHO), an average of one in ten patients are affected by health care associated infections (HAIs). HAIs harm patients, healthcare workers, and visitors, cause disability and death, and cost billions of dollars each year in additional healthcare expenses. Hand hygiene compliance averts the spread of bacteria and viruses, particularly those showing antibiotic resistance.

Hospitals and health-care services must define the organization’s hand hygiene practices, goals, and guidelines. Three of the most common methods of measuring hand hygiene compliance are direct observation, self-reporting of health-care workers, and indirect measurements of hygiene product (liquid soap, hand sanitizer, and paper towels) usage from refilling frequency and amount. Observing employee behavior, self-reporting, and peer monitoring allows administrators and managers to determine the most relevant approach for employees based on the gathered baseline data. Hospitals and health-care settings must ensure sterile environments for operations, daily examinations, and patient well-being.

Background

Assessing hand hygiene techniques is essential in generating methods to increase compliance from health-care workers and visitors. However, it is as essential to measure the frequency and conditions with which employees practice proper hand hygiene. Health-care administrators and managers must observe and question employees to assess if sanitary guidelines are being followed to determine whether employees are using the correct quantity of liquid soap or alcohol-based hand rub per wash, spend a satisfactory amount of time using hand hygiene products, use paper towels when turning off faucets to minimize re-contamination, and wear and remove gloves correctly to avoid contamination. Likewise, proper hand hygiene is dependent on personal articles and features such as long fingernails, artificial nails, and jewelry that can hinder compliance if additional action is required per wash or if the articles trap additional contaminants when hand hygiene guidelines are not followed precisely.

Health-care administrators and managers often have difficulty monitoring hand hygiene compliance because patient contact between the individual and the environment occurs at varying locations across the health-care setting. Likewise, hand hygiene opportunities for both clinical and nonclinical staff occur around the clock. Clinicians require different frequencies and intensities of hand hygiene depending on the type of care they have provided as well as the patient factors. For example, clinicians who examine a patient with a fever would require milder handwashing compared to those who handle vomiting patients. Monitoring hand hygiene compliance is time-consuming; managers may not always be able to divert health-care specialists from their other duties to monitor hand hygiene methods, especially infection prevention specialists, quality improvement staff, nurses, and respiratory therapists. Moreover, close monitoring of hygiene practices may stimulate the Hawthorne effect, where subjects alter behavior and actions when observed in close proximity.

In 2002, the CDC provided restructured and updated hand hygiene guidelines for the United States. In 2004, the World Health Organization (WHO) launched the World Alliance for Patient Safety, a program to emphasize and endorse hand hygiene compliance in health care as a means to eliminate nosocomial infections.

Hand Hygiene Compliance Today

Hand hygiene compliance is a global interest as it can affect any person in any hospital. Both the CDC and WHO advocate constant monitoring of all health-care settings to maintain and improve hand hygiene compliance. The WHO has recommended other instances where hand hygiene compliance is necessary: before contact with patients (prior to approaching the patient), before all aseptic (sterile environment) tasks, after exposure to bodily fluids, after glove removal, after contact with the patient, and after contact with the patient’s environment. The nonprofit organizations National Quality Forum and the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations and Joint Commission on Accreditation of Hospitals) both endorse the CDC and WHO guidelines and have suggested other means of administrator monitoring, such as during patient observations and the use of hand hygiene compliance systems that electronically monitor product volume or count the number of times hand hygiene apparatus is used. It was suggested that the implementation of single-level and multilevel hand hygiene interventions—adding more dispensers, education and involvement of patients and staff, feedback initiatives, social marketing, and cultural and organizational change—can alter compliance rates based on social and cultural aspects. Beginning in 2004 hand hygiene compliance was considered for accreditation. In early 2018, Modern Healthcare reported that as of January 2018, the Joint Commission, which provides accreditation for healthcare facilities, will cite an organization if noncompliance with the hand hygiene protocol is observed during periodic reviews.

Leadership support can elevate hand hygiene compliance in hospitals and health-care settings. The Association for Professionals in Infection Control and Epidemiology (APIC) has suggested the following eight guidelines for promoting hand hygiene among health-care employees: (1) The health-care organization’s leadership must fully support hand hygiene compliance initiatives. (2) Continuous monitoring and response must be available for tracking current and developing endemic infections and drug-resistant pathogens. (3) Senior administrators must create a multidisciplinary design and response team dedicated to hand hygiene compliance. (4) Health-care facilities must provide education and training for staff, patients, families, caregivers, and visitors. (5) Hand hygiene resources, such as hand sanitizer stations and disinfectant wipes, must be readily available in all hallways, entrances, and exit pathways. (6) Administrators can emphasize accountability for good hygiene by recognizing and rewarding hand hygiene compliance among employees. (7) Visual resources with relevant facts and statistics, such as instructive reports, posters, pocket cards, and brochures, can serve as constant reminders. Health-care organizations should direct observers, coworkers, patients, and visitors to give health-care workers feedback in real time. (8) Monitoring and feedback programs can inform employees of the hospital’s monthly compliance data and encourage employees to discuss these findings with colleagues.

Successful hand hygiene compliance can be accomplished from continuous emphasis on hand hygiene messages, administrator acknowledgement of clinical staff’s perception on hand hygiene, supervision of hand hygiene exercises, educational tools, and having senior staff role models. In addition, patient engagement was reported to increase hand hygiene compliance, wherein patients were encouraged to ask clinical staff if they had washed their hands. Successful hand hygiene compliance requires multimodal participation and health care–community involvement to minimize the spread of preventable nosocomial infections in and around health-care settings.

Bibliography

APIC. APIC Implementation Guide: Guide to Hand Hygiene Programs for Infection Prevention. APIC, June 2015.

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Pfoh, Elizabeth, Sydney Dy, and Cyrus Engineer. "Chapter 8: Interventions to Improve Hand Hygiene Compliance: Brief Update Review." Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Agency for Healthcare Research and Quality, Mar. 2013. Evidence Reports/Technology Assessments, 211. NCBI, www.ncbi.nlm.nih.gov/pmc/articles/PMC4781147/. Accessed 25 Sept. 2024.

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