WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
16.
Hand hygiene practices among health-care
workers and adherence to recommendations
16.1 Hand hygiene practices among health-care
workers
Understanding hand hygiene practices among HCWs
is essential in planning interventions in health care. In
observational studies conducted in hospitals, HCWs cleaned
their hands on average from 5 to as many as 42 times
per shift and 1.7–15.2 times per hour (Table I.16.1). 79,137,217-
219,262,264,611,613,623,624,647-655
The average frequency of hand hygiene
episodes fluctuates with the method used for monitoring (see
Part III, Section 1.1) and the setting where the observations were
conducted; it ranges from 0.7 to 30 episodes per hour (Table
I.16.1). On the other hand, the average number of opportunities
for hand hygiene per HCW varies markedly between hospital
wards; nurses in paediatric wards, for example, had an average
of eight opportunities for hand hygiene per hour of patient
care, compared with an average of 30 for nurses in ICUs. 334,656
In some acute clinical situations, the patient is cared for by
several HCWs at the same time and, on average, as many as
82 hand hygiene opportunities per patient per hour of care have
been observed at post-anaesthesia care unit admission. 652 The
number of opportunities for hand hygiene depends largely on
the process of care provided: revision of protocols for patient
care may reduce unnecessary contacts and, consequently,
hand hygiene opportunities. 657
In 11 observational studies, the duration of hand
cleansing episodes by HCWs ranged on average from
as short as 6.6 seconds to 30 seconds. In 10 of these
studies, the hand hygiene technique monitored was
handwashing, 79,124,135,213-216,218,572,611 while handrubbing was
monitored in one study. 457 .In addition to washing their hands for
very short time periods, HCWs often failed to cover all surfaces
of their hands and fingers. 611,658 In summary, the number of hand
hygiene opportunities per hour of care may be very high and,
even if the hand hygiene compliance is high too, the applied
technique may be inadequate.
16.2 Observed adherence to hand cleansing
Adherence of HCWs to recommended hand hygiene
procedures has been reported with very variable figures, in
some cases unacceptably poor, with mean baseline rates
ranging from 5% to 89%, representing an overall average of
38.7% (Table I.16.2). 60,140,215,216,334,335,485,486,492,493,496,497,613,633,637,648-
651,654,655,657,659-711
It should be pointed out that the methods
for defining adherence (or non-adherence) and the
methods for conducting observations varied considerably
in the reported studies, and many articles did not include
detailed information about the methods and criteria used.
Some studies assessed compliance with hand hygiene
concerning the same patient, 60,334,648,652,666,667,683,685-687
and an increasing number have recently evaluated
hand hygiene compliance after contact with the patient
60,334,648,652,654,657,670,682,683,686,687,691,698,700-702,704,707-709,711 ,712
environment.
A number of investigators reported improved adherence after
implementing various interventions, but most studies had short
follow-up periods and did not establish if improvements were
of long duration. Few studies reported sustained improvement
as a consequence of the long-running implementation of
programmes aimed at promoting optimal adherence to hand
hygiene policies. 60,494,657,713-719
16.3 Factors affecting adherence
Factors that may influence hand hygiene include risk factors
for non-adherence identified in epidemiological studies and
reasons reported by HCWs for lack of adherence to hand
hygiene recommendations.
Risk factors for poor adherence to hand hygiene have been
determined objectively in several observational studies or
interventions to improve adherence. 608,656,663,666,720-725 Among
these, being a doctor or a nursing assistant, rather than a
nurse, was consistently associated with reduced adherence.
In addition, compliance with hand cleansing may vary among
doctors from different specialities. 335 Table I.16.3 lists the major
factors identified in observational studies of hand hygiene
behaviour in health care.
In a landmark study, 656 the investigators identified hospitalwide
predictors of poor adherence to recommended hand hygiene
measures during routine patient care. Predicting variables
included professional category, hospital ward, time of day/week,
and type and intensity of patient care, defined as the number of
opportunities for hand hygiene per hour of patient care. In 2834
observed opportunities for hand hygiene, average adherence
was 48%. In multivariate analysis, non-adherence was the
lowest among nurses compared with other HCWs and during
weekends. Non-adherence was higher in ICUs compared with
internal medicine, during procedures that carried a high risk
of bacterial contamination, and when intensity of patient care
was high. In other words, the higher the demand for hand
hygiene, the lower the adherence. The lowest adherence rate
(36%) was found in ICUs, where indications for hand hygiene
were typically more frequent (on average, 22 opportunities per
patient-hour). The highest adherence rate (59%) was observed
in paediatrics, where the average intensity of patient care
was lower than elsewhere (on average, eight opportunities
per patient-hour). The results of this study suggested that
full adherence to previous guidelines was unrealistic and that
easy access to hand hygiene at the point of patient care, i.e.
in particular through alcohol-based handrubbing, could help
improve adherence, 615,656,720 Three recent publications evaluating
the implementation of the CDC hand hygiene guidelines 58 in the
USA tend to concur with these results and considerations. 726-728
Various other studies have confirmed an inverse relation
between intensity of patient care and adherence to hand
hygiene. 60,334,335,493,649,652,653,656,689,729,730
66