Hand hygiene: are we doing better?

Healthcare Purchasing News, Dec, 2005 by Cynthia T. Crosby

It has been three years since the Guidelines for Hand Hygiene in Health-Care Settings were published by the Centers for Disease Control and Prevention (CDC). (1) Several factors have contributed to interest in hand hygiene, including increased awareness of healthcare workers and the public about risks associated with nosocomial infections, the adoption of educational programs designed to lower the incidence of surgical site infections, and the wider availability of alcohol based hand rubs.

Has the attention given to hand hygiene produced any changes in the healthcare setting? Information about the effects of internal education programs to promote hand hygiene and the effectiveness and use of alcohol-based hand rubs is reviewed.

Hand hygiene education and compliance efforts

An attempt to improve compliance with hand hygiene guidelines was undertaken in intensive care units (ICUs) in a tertiary care hospital. Methods included education, training, and performance feedback. Compliance was measured during routine patient care in medical surgical and coronary ICUs before and during implementation of hand hygiene. The incidence of nosocomial infections was tracked as an outcome measure. Nosocomial infections were identified using National Nosocomial Infections Surveillance (NNIS) criteria. There were 4,347 opportunities for hand hygiene in the ICUs during the evaluation period. Compliance with hand hygiene protocols increased from 23% before implementation to 65% after implementation (Figure 1). During the same period, overall nosocomial infections in the ICUs decreased from 48 per 1,000 patient days to 28 per 1,000 patient days (Figure 2). (2)

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Using a more direct interventional process, a surgical intermediate care unit in a university setting implemented electric monitoring of hand hygiene. Computerized voice prompts were elicited if healthcare workers left the room without performing hand hygiene protocols. All patient rooms, utility rooms, and the staff lavatory were electronically monitored. Participants included all physicians, nurses, nursing support personnel, ancillary staff, family member, visitors, and anyone else who interacted with patients within the unit. All patients who stayed in the unit for at least 48 hours were tracked for nosocomial infections. Electronic monitoring recorded 283,488 entries and 251,526 exits into and from patient rooms for 420 days. Use of electronic monitoring improved hand hygiene compliance by 37%, and nosocomial infections decreased by 22%. The addition of computerized voice prompts increased hand hygiene compliance 41% compared to baseline, and nosocomial infections decreased 48% overall. In this study, electronic monitoring provided effective feedback and improved compliance. (3)

In another evaluation of infection control policies, a cross-sectional study was performed using survey data and the Pediatric Health Information System database, which includes information from 35 children's hospitals. Data were gathered for patients undergoing elective surgical procedures. Of 35 eligible hospitals, 31 (89%) participated. A total of 48,272 patients were included in the study. Among the 31 hospitals evaluated, only 12 monitored hand hygiene. A total of 19 used administrative support of hand hygiene for compliance, and 16 provided alcohol-based hand gel. The presence of hand gel was significantly associated with lower rates of gastrointestinal infections (adjusted odds ratio: 0.64; 95% confidence interval: 0.49 0.85). (4)

Alcohol-based hand rubs

The CDC guidelines endorse the use of alcohol-based hand rubs in several settings (Table 1). At the same time, additional support for their use has appeared in the medical literature, with many proponents advocating alcohol based hand robs because they are associated with better compliance than hand scrubbing. Improved compliance is linked to reduced time and less use of alcohol-based hand rubs. (5)

In a study conducted in a medical and surgical ICU, hand hygiene behavior was observed and effects of alcohol-based hand rubs on microbial flora were monitored, compared to handwashing with plain liquid soap. The crude compliance rate with hand hygiene procedures was 50%, and adequate compliance was 21%. Alcohol-based hand rubs were recommended because there was less sensitivity toward microbial growth with hand gel use compared to hand washing. (6)

Efforts to improve

Hand hygiene protocols, educational efforts, and antiseptic products will vary substantially from one facility to another. The common denominator, however, is the effort healthcare facilities are taking to improve compliance and reduce nosocomial infection rates. In some cases, infection monitoring and educational efforts have resulted in recommendations for particular product use, as in the case of alcohol-based hand rubs. (4,6) The most promising aspect of this effort, whether it is through education, product adoption, or a combination of efforts, is that nosocomial infections can be decreased. Both education and attention to product evaluation play a role in effective hand hygiene protocols. It is up to each facility to develop and monitor practices for the benefit of their patients.