By Kelly M. Pyrek
This article originally appeared in the December 2019 issue of Healthcare Hygiene magazine.
Studies have extensively documented the suboptimal rates of hand hygiene compliance by healthcare personnel, as well as established the numerous barriers to compliance. One of the very latest data sets is provided by Salmon, et al. (2019); the researchers conducted a hospital-wide survey followed by profession-specific focus group discussions to investigate impact, perceptions and areas for improvement in handwashing. Their results showed a good understanding that hand hygiene is a crucial part of the infection-prevention program; however, the acceptance and impact of messages varied between professions and required tailoring. The researchers say that motivation, use of influential role models and social cohesion should be considered when designing profession-specific messages to improve infection-prevention-related change uptake among healthcare workers (HCWs).
Their results revealed that HCWs acknowledge the serious consequences of developing a hospital-acquired infection (HAI); however, 35 percent of physicians, 32 percent of allied health workers and 20 percent of nurses admitted to omitting hand hygiene in preference to focusing on the clinical task. Similarly, 35 percent of physicians, 40 percent of allied health workers and 25 percent of nurses struggled to remember the right ‘moment’ to perform hand hygiene. The researchers found that nurses were the most engaged in the hand hygiene program, including identifying ward hand hygiene champions. Interventions to motivate hand-hygiene compliance varied between professions with 56 percent of nurses strongly encouraged by dance videos or fun activities, whereas 80 percent of physicians and 55 percent of allied health professionals preferred serious messages via scientific presentations or e-mails.
As Salmon, et al. (2019) observe, “Accounting for professional characteristics can enhance acceptance of behavior-change interventions that are crucial for infection prevention and control programs. Program design must consider the audience – personality, background and preference for messaging for impact. Without such considerations, we are missing the opportunity to engage HCWs and change behavior. Our discussions showed that a one-size program does not fit all, and adjustments need to be tailored for infection prevention programs to be successful, cost effective and sustainable.”
Taking direction from the points raised in the study by Salmon, et al. (2019), let’s examine several key issues.
Remembering the Right Moment for Hand Hygiene
Defining opportunities must be an ongoing educational objective in healthcare institutions.
Ellingson, et al. (2014) remind us that to measure hand hygiene adherence, the opportunities for hand hygiene must be defined in clear and measurable ways. The most commonly recognized framework for measuring hand hygiene opportunities is the World Health Organization (WHO)'s 5 Moments for Hand Hygiene. As the experts explain, these moments include the many indications for hand hygiene defined in the CDC and WHO guidelines summarized into "moments" to promote clarity in education and measurement.
The 5 Moments for Hand Hygiene
Moment 1: Before touching the patient, to prevent colonization of the patient with healthcare-associated microorganisms
Moment 2: Before a clean/aseptic procedure, to prevent an HAI that could arise from the patient's endogenous microorganisms or microorganisms on healthcare personnel (HCP) hands or in the environment.
Moment 3: After body fluid exposure, to reduce the risk of colonization or infection of HCP and to reduce the risk of transmission of microorganisms from a colonized site to a clean site on the same patient.
Moment 4: After touching the patient, to minimize the risk of transmitting microorganisms to the healthcare environment and to protect HCP by reducing contamination on their hands
Moment 5: After touching patient surroundings, as hand contact with patient objects is associated with hand contamination
Significant variation in hand hygiene opportunities across institutions has been observed by numerous researchers. As Ellingson, et al. (2014) explain, “Some organizations teach the concepts of the 5 moments but simplify measurement by observing hand hygiene opportunities only before and after care (the entry and exit method). Many institutions in the U.S. have, for communication and assessment purposes, compressed the number of hand hygiene opportunities to entry to and exit from a patient care area, which roughly corresponds with the WHO's moment 1 and moment 4 or 5. Although there is some concern that this leaves out moment 2 (before an aseptic procedure) and other opportunities for contamination within the patient care encounter, there is some evidence that the entry and exit method may be an adequate proxy for measurement of hand hygiene for the entire patient encounter.”
The researchers continue, “Operationally, the entry and exit method is easier to institute for measurement purposes and respects patient privacy. Emphasis on moment 1 and moment 4 (or 5) also highlights the priority for reducing cross-transmission of pathogens in healthcare … The CDC's protocol for multidrug-resistant organism and C. difficile infection (CDI) surveillance includes hand hygiene measurement as a ‘supplemental prevention process measure.’ For simplification of measurement, the protocol stipulates observation of hand hygiene opportunities after healthcare personnel con tact with a patient or with inanimate objects in the vicinity of the patient (moments 4 and 5 only). Monitoring hand hygiene on exit from a patient room (or after care) is convenient for observers because the indication for hand hygiene is obvious.”
Efficacy of Hand Hygiene
One of the challenges of convincing HCWs about the criticality of hand hygiene is the lack of randomized trials or epidemiologically rigorous observational studies, despite numerous strong recommendations in the CDC and WHO guidelines.
Ellingson, et al. (2014) observe, “This lack of rigor occurs in part because of ethical considerations in randomizing control groups and in part because investment in the science behind hand hygiene has lagged behind other healthcare research topics.” They add, “The lack of randomized trials to test recommendations for hand hygiene indications that have become standard of care is likely to persist, largely due to ethical concerns. However, more rigorous studies could provide a better evidence base for other important aspects of hand hygiene, such as optimizing methods for hand hygiene measurement. Similarly, more rigorous multisite studies of implementation of hand hygiene programs and studies of hand hygiene in non-acute care settings are needed. Finally, establishing consistent methods for assessing the efficacy of various products relative to the volume and technique used in clinical settings is critical.”
Regarding hand hygiene product efficacy, studies have been conducted to compare the relative efficacy of various hand hygiene products against bacteria. In most studies, ABHRs (with alcohol concentrations between 62 percent and 95 percent) are described as being more effective than either plain or antimicrobial soaps over a broad range of testing conditions.
Of clinical studies of hand hygiene product efficacy against bacteria that compare ABHR with soap products in use by HCP, many report ABHR to be superior to soap formulations or at least equivalence of ABHR with soap products. Likewise, most studies show that ABHRs have significantly better efficacy in removing several different viruses than nonantimicrobial and antimicrobial soap and water, suggesting that ABHRs are likely to provide some protection against several respiratory and enteric viruses on the hands.
As Ellingson, et al. (2014) caution, “One issue of concern is that study conditions may not always be reflective of clinical situations because artificial contamination with microorganisms and controlled hand hygiene regimens are sometimes used.
Regarding efficacy based on dispensing mechanism, Ellingson, et al. (2014) report that alcohol-containing wipes have been reported to have similar efficacy to ABHR gel and foam against influenza virus. It appears that some formulations of alcohol-based wipes with at least 65% alcohol are now comparable to alcohols delivered by other dispensing methods.
When it comes to hand hygiene technique, the CDC and WHO guidelines provide general guidance on technique and recommend that manufacturer guidance be followed for volume of hand hygiene product used and contact time of product. The minimum time required by manufacturers is generally 15-20 seconds, with the volume required changing on the basis of the size of the hands to meet the time requirement. As Ellingson, et al. (2014) state, “Recent studies suggest that 15 seconds is insufficient for meeting standards for high-quality hand disinfection (EN 1500) and that physical coverage of hands with hand hygiene product in clinical settings is often substandard.”
Hand hygiene expert Didier Pittet at the University of Geneva Hospitals and his co-investigators (Pires, et al. 2018) are among the researchers who put to the test the log10 reduction of bacteria on hands after washing and after using alcohol-based handrub (ABHR). Pittet emphasizes that “There is a greater reduction with ABHR,” and points to the European norms that manufacturers must follow that are based on microbiological efficacy.
Pires, et al. (2018) state that, “Compliance with the World Health Organization 'how to handrub' action is suboptimal. Simplifying the hand-hygiene action may improve practice. However, it is crucial to preserve antibacterial efficacy.” The researchers tested the non-inferiority of 15 versus 30 seconds handrubbing for Staphylococcus aureus and Escherichia coli contamination at different loads, using hand-size customized alcohol-based handrub (ABHR) volumes.
In this EN1500-based study, 18 HCWs with extensive experience in hand hygiene rubbed hands with a hand-size customized volume of isopropanol 60% v/v. They repeated the following sequence: hand contamination (E. coli or S. aureus; broth containing 108 or 106 CFU/mL); baseline fingertips sampling; handrubbing (15 or 30 seconds); re-sampling. The main outcome was log10 CFU corrected reduction factor (cRF) on HCWs' hands, applying a generalized linear mixed model with a random intercept for subject.
According to Pires, et al. (2018), the median cRF was 2.1 log10 (interquartile range 1.50-3.10). After fitting the model, cRF was significantly higher for S. aureus compared with E. coli but there was no significant effect for duration of handrubbing or contamination fluid concentration. Fifteen seconds of handrubbing was non-inferior to 30 (-0.06 log10, 95% CI -0.34 to 0.22; EN1500 0.60 log10 non-inferiority margin). This was confirmed in all pre-specified subgroups.
The researchers concluded that among experienced HCWs using a hand-size customized volume of ABHR, handrubbing for 15 seconds was non-inferior to 30 seconds in reducing bacterial load, irrespective of type of bacteria or contamination fluid concentration. This provides further support for a shorter, 15-seconds, hand-hygiene action.
In 2009, the WHO published guidance on a standardized multistep technique to promote coverage of all surfaces of the hands with hand hygiene product, estimating 20-30 seconds for hand rubbing and 40-60 seconds for handwashing with soap and water.
Studies have shown that training HCP on proper technique can increase coverage and decrease bacterial counts on the hands of HCP. As Ellingson, et al. (2014) point out, “Some studies have indicated that rigid adherence to standardized step-by-step technique may not be as critical by demonstrating that sufficient pathogen reductions could be achieved by instructing HCP simply to cover their hands with hand hygiene product (the ‘reasonable application’ approach) regardless of technique used. However, the studies finding reasonable application equivalent to a standardized technique had protocols using 3 mL of product, and it is unclear how often this volume is used in clinical practice (due to longer drying times associated with use of higher volumes). The standard dispenser actuation for ABHRs is 1.1 mL, although a recent study showed variability from 0.6 to 1.3 mL of product dispensed with each actuation. Two studies published in 2013 report conflicting findings on whether 1.1 mL is sufficient to meet the Food and Drug Administration (FDA) requirement for log reductions.
Best Practices for Proper Hand Hygiene
Basic practices for hand hygiene:
- Select appropriate products.
- Provide convenient access to hand hygiene equipment and products by placing them strategically and assuring that they are refilled routinely as often as required.
- Involve HCP in choosing products.
- Perform hand hygiene with an ABHR or, alternatively, an antimicrobial or nonantimicrobial soap for the following indications.
- Perform hand hygiene with antimicrobial or nonantimicrobial soap when hands are visibly soiled.
- Assess unit- or institution-specific barriers to hand hygiene with frontline HCP for the purpose of identifying interventions that will be locally relevant.
- Implement a multimodal strategy (or "bundle") for improving hand hygiene adherence to directly address the organization's most significant barriers.
- Educate, motivate, and ensure competency of HCP
- Measure hand hygiene adherence via direct observation (human observers), product volume measurement, or automated monitoring.
- Provide feedback to HCP on hand hygiene performance.
Basic practices for performance measurement:
- Direct observation: a human observer audits a healthcare area (either in person or by video monitoring) and observes whether HCP perform hand hygiene for a prespecified set of indications
- Product volume measurement: milliliters of hand hygiene product used for a specified period of time in a specified area per 1,000 patient-days during specified period in specified
- Automated monitoring: electronic counting, meaning the number of dispensing episodes per patient-day; or radiofrequency identification, wireless, ultrasound, or infrared sensing for a number of approximated hand hygiene opportunities detected by sensors
Basic practices for engagement:
- Define the barriers to hand hygiene that are specific to the unit or institution
- Ensure that institutional leadership is aware and supportive of hand hygiene improvement strategies and supports these efforts with adequate resources
- Utilize peer networking to encourage persistent salience of hand hygiene
- Consider rewards or recognition for wards modeling good hand hygiene behaviors or improvement
- Encourage patients to take an active role in reminding doctors to perform hand hygiene
Basic practices for education and improvement:
- Educate providers on recommended indications and techniques for hand hygiene by using educational tools that clearly define hand hygiene indications and teach the logic behind each one
- Consider targeting education to specific groups or facility-specific knowledge gaps or misconceptions 3. Assess competency regarding hand hygiene with tests of didactic knowledge and demonstration of proper hand hygiene techniques
- Implement a multi-modal hand hygiene improvement program
- Recognize that interventions must be ongoing to maintain behavior change and improved adherence
- Identify barriers to hand hygiene specific to the unit or institution.
- Focus on targeted behavior change
- Measure hand hygiene adherence performance, adjusted for facility-specific needs
- Provide meaningful feedback on hand hygiene performance with clear targets and an action plan in place for improving adherence
- Use feedback to engage HCP in identifying problems at the individual hospital or unit level, and use data to tailor ongoing interventions
In the real world, breaking down barriers and boosting compliance comes down to translating the science into practical recommendations for your individual setting and its unique challenges.
“Healthcare personnel must understand how important hand hygiene is for protecting patients,” says Pittet. “Institutions play a big role in compliance and need to implement a multimodal strategy. Healthcare workers need to be trained, motivated, reminded, and there needs to be a safety culture within the institution. It is also important that handrub (or in certain cases running water) is available, that the handrub is a formulation that is well-tolerated by skin, etc.”
“Getting your hand hygiene program to the next level just depends on what the barriers are,” confirms Paul Pottinger, MD, FACP, FIDSA, professor of medicine in the Division of Allergy & Infectious Diseases at the University of Washington Medical Center in Seattle. “It is so important to figure out who is having trouble, and where, when and why. The issue may be ignorance--or heaven forbid, indifference. For example, if you have a small number of individuals within a specific service, then an intensive education intervention may pay off--if you include the service head, and make it clear that the head is a partner in this process who will be accountable for their team's performance. The issue may be due to poor infrastructure. For example, if hand gel stations or sinks are not accessible at point of care, then we can hardly blame healthcare workers for imperfect compliance. Plumbing, not education, would be the solution. Finally, a common issue is just good old complacency. For instance, you may find that a team performs perfect hand hygiene 95 percent of the time. That’s pretty good, but there's still room for improvement. Everyone is human, and humans do make mistakes! In my own practice, I model hand hygiene for the trainees under my supervision, but I am humble about my own failings, and challenge the fellows and residents to call me out if they see me fail to perform hand hygiene: A free latte for each trainee who catches me! The point is, getting your program to the next level will probably require different interventions, depending on the source of the gap. Talking to people and watching their behavior always pays off.”
“If hand hygiene is performed as recommended, then it is an extremely effective infection prevention measure,” emphasizes Claudette Poole, MD, assistant professor in pediatric infectious diseases and associate fellowship program director for infectious disease at Children’s of Alabama. “The challenge however is incorporating the behavior into the routine course of healthcare, which becomes increasingly challenging as the complexity of care increases. I think it is extremely helpful to have independent observers, and ideally experts in human behavior to evaluate how physical spaces are set up, and the physical steps required during care encounters. It can be extremely enlightening to realize that many healthcare delivery spaces are not set up well, and actually make it harder rather than easier for healthcare providers to be compliant.”
Making it easier for healthcare professionals to do the right thing when it comes to hand hygiene compliance has been touted as the go-to practice by experts.
“There is no substitute for customizing interventions to suit the particular needs of particular groups,” says Pottinger. “As long as healthcare workers have a chance to share their perspectives and so long as infection control takes those conversations into account, you will make progress. On the other hand, we risk failure when we superimpose solutions onto providers without their participation in the process.”
Pittet suggests that making hand hygiene easier entails “Having alcohol-based handrub available at each patient’s bedside and making people understand the importance of their compliance. Measure compliance using the WHO 5 moments, motivate the workforce, make sure there is sufficient training available. Behavior change is an ongoing process, one is never done teaching, giving monitoring feedback, or motivating people.”
Myriad monitoring interventions exist, with advantages and drawbacks to each, and institutions must determine for themselves what works best to boost compliance.
“At my center, we use a combination of direct observation and secret shopper observation, with all data logged via a proprietary app entered on a mobile device,” says Pottinger. “But, regardless of which system is in place at a given location or time, one of the challenges we face should feel familiar to everyone: If observers are stationed in the hallway, they may lack information about compliance with hand hygiene opportunities in the patient room itself. I don't have an easy solution for this, because putting observers in patient rooms is often impossible, or inappropriate, but it is an opportunity for improvement, because so many ‘hand hygiene moments’ happen right at the bedside, and we may miss them.”
Pittet says he is a fan of an old-school method that remains controversial. “The gold standard is still direct observation,” he asserts. “In our hospital we let the healthcare workers know we are observing them, and we provide direct feedback after the monitoring. That way the monitoring is positive and an opportunity for learning, not punitive. Although compliance may seem higher when healthcare workers know they are being watched, the important thing is changing their behavior, not making sure that the number for hand hygiene compliance is perfectly accurate. It is more important to improve than to hit a specific target.”
Pittet continues, “There is a lot of potential for electronic monitoring systems, but at this time there are none that can measure the WHEN of the handrub (the WHO 5 moments). If one day a system can measure these five moments, it will be a revolution in hand hygiene. For now, direct observation with validated observers that give feedback directly to the healthcare worker in a confidential way is the most effective way of monitoring that we have found. It is important that people feel like they are being supported by their IP&C teams instead of policed.”
Monitoring and collecting hand hygiene-compliance data is a complicated task, compounded by the necessity of making sense of it and further using it to improve compliance.
“In our practice, meaningful data are detailed data: Instead of a unit-based percentage of compliance, we provide service chiefs with information about total number of observations and the percent of compliant encounters based on job title,” says Pottinger. “In this way, leaders can decide whether they need to intervene with particular groups of providers. And, no one escapes the view of our eagle-eyed observers! All workers who enter and leave the room are subject to their scrutiny, and the immediate, polite, friendly, supportive feedback of our direct observers.”
“When data is collected on the 5 moments, one can measure institutional compliance, compliance by ward, by type of healthcare worker, and compliance by (WHO 5 moments) moment,” Pittet says. “.For example, if you notice that there is much lower compliance before aseptic procedures, you could do a training for hand hygiene specifically before aseptic procedures. If you notice that hand hygiene is much worse in the obstetrics ward, or among doctors, you could target that population with trainings or other initiatives.) You can also use this data to fill out the Hand Hygiene Self-Assessment Framework, which will allow you to analyze your institution, and see what elements your specific institution needs to improve on. It also allows you to compare your institution to others around the world.”
Poole cautions about monitoring: “Monitoring is not the answer. All healthcare providers come to work every day with the intention of doing the best for their patients. As institutions we need to determine what is making it hard for providers to comply. Are provisions sufficient and conveniently placed? Are provider to patient ratios reasonable? Are we expecting too many disparate tasks to be performed and are we providing enough ancillary support?”
Poole continues, “Much has been written about the inaccuracy of the current measures to collect HH data. In its current forms I am not certain how helpful they are in improving compliance. The most effective measures that have been shown to work are design solutions and incorporation of bundles. In general institutions that have an overall focus on patient safety, infection prevention and performance improvement where all levels from executive leadership to housekeeping and ancillary staff share in that focus, will tend to see a decrease in hospital associated infections.”
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Pires D, Soule H, Bellissimo-Rodrigues F, de Kraker MEA and Pittet D. Antibacterial efficacy of handrubbing for 15 versus 30 seconds: EN 1500-based randomized experimental study with different loads of Staphylococcus aureus and Escherichia coli. Clin Microbiol Infect. 2019 Jul;25(7):851-856. doi: 10.1016/j.cmi.2018.10.012. Epub Oct 26, 2018.
Salmon S, Phua MY and Fisher D. One size does not fit all: the effectiveness of messaging for hand hygiene compliance by profession in a tertiary hospital. J Hosp Infect. Sept. 13, 2019