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14. HAND HYGIENE PRACTICES AMONG HEALTH-CARE WORKERS AND ADHERENCE TO RECOMMENDED PRACTICES 14.1 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 five times to as many as 30 times per shift (Table I.14.1) 35,82,154,190,454,498 . The average frequency of hand hygiene episodes fluctuates with the observed compliance and the setting where the observations were made, and ranges from 0.7 to 12 episodes per hour (Table I.14.1). 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 22 opportunities for nurses in ICUs 485 . In some acute clinical situations, the patient is cared for 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 499 . 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. In 17 observational studies, the duration of hand cleansing episodes by HCWs ranged on average between as little as 6.6 seconds and 30 seconds. In 16 of these studies, the hand hygiene technique used was handwashing 35,70,80,148-151,153,426,457 , and handrubbing was used in one study 342 (Figure I.14.1). In addition to washing their hands for very short time periods, HCWs often failed to cover all surfaces of their hands and fingers 498 . In summary, the frequency of hand hygiene opportunities per hour of care may be very high, and despite the hand hygiene compliance rate, the applied technique may fail. Figure I.14.1 Average duration of hand cleansing by health-care workers Sources: 35,70,80,148-151,153,342,426,457 153 342 426 457.
14.2 OBSERVED ADHERENCE TO HAND CLEANSING Adherence of HCWs to recommended hand hygiene procedures has been unacceptably poor, with mean baseline rates ranging from 5% to 81%, with an overall average of about 40% (Table I.14.2) 150,151,261-263,359,360,459,475,476,480,482,500-534 . 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 261,262,499,507,508,525,527-529,531 , and few evaluated hand hygiene compliance after contact with the environment related to the pat ient 261,262,499,511,524,525,528,529,531 . 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 262,535,536 proved that sustained improvements occurred during a long-term programme to improve adherence to hand hygiene policies. 14.3 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 454,485,504,507,537-542 . 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 specialties 263 . Table I.14.3 lists the major factors identified in observational studies of hand hygiene behaviour in health care. In the largest survey conducted so far 485 , the investigators identified hospital-wide 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, 20 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 suggest that full adherence to previous guidelines may be unrealistic and that easy access to hand hygiene could help improve adherence 461,485,537 . Recent studies have confirmed an inverse relation between intensity of patient care and adherence to hand hygiene 263,499,543 . Perceived barriers to adherence with hand hygiene practice recommendations include skin irritation caused by hand hygiene agents, inaccessible hand hygiene supplies, interference with HCW–patient relationships, patient needs perceived as a priority over hand hygiene, wearing of gloves, forgetfulness, lack of knowledge of guidelines, insufficient time for hand hygiene, high workload and understaffing, and the lack of scientific information showing a definitive impact of improved hand hygiene on HCAI rates 454,485,504,507,539-541,544 . Some of the perceived barriers to adherence with hand hygiene guidelines have been assessed or
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The WHO Guidelines on Hand Hygiene
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CONTENTS INTRODUCTION . ...........
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17. Organizing an education program
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INTRODUCTION The WHO Advanced Draft
Page 14 and 15: Handwashing. Washing hands with pla
Page 16 and 17: still considered the standard of ca
Page 18 and 19: treatment selectively removes glyce
Page 20 and 21: of the organism on their hands. Mak
Page 22 and 23: 6. MODELS OF HAND TRANSMISSION 6.1
Page 24 and 25: In the 1960s, a prospective, contro
Page 26 and 27: for its ability to reduce the relea
Page 28 and 29: 8.2 SHORTCOMINGS OF TRADITIONAL TES
Page 30 and 31: tions of short-chain aliphatic alco
Page 32 and 33: 9.1.3 WATER QUALITY The physical, c
Page 34 and 35: Case study: experience of Egypt The
Page 36 and 37: and both reduced viral counts on ha
Page 38 and 39: activity of chlorhexidine is not se
Page 40 and 41: protein synthesis and alteration of
Page 42 and 43: in micelle structures formed by sur
Page 44 and 45: In all the studies that included pl
Page 46 and 47: isopropyl alcohol) were applied to
Page 48 and 49: 3) Glycerol is added using a measur
Page 50 and 51: in 2005 the costs of an alcohol-bas
Page 52 and 53: infection, risk factors that are la
Page 54 and 55: 11.4.4 SIDE-EFFECTS OF THE SURGICAL
Page 56 and 57: • Repeat the process on the other
Page 58 and 59: 12.2 ALLERGIC CONTACT DERMATITIS RE
Page 60 and 61: particularly when resources are lim
Page 62 and 63: Handrubs are available as gels, sol
Page 66 and 67: quantified in observational studies
Page 68 and 69: According to behavioural theories (
Page 70 and 71: of water with special leaves) outsi
Page 72 and 73: Furthermore, according to Phra Depv
Page 74 and 75: 16. BEHAVIOURAL CONSIDERATIONS 16.1
Page 76 and 77: and community factors must be consi
Page 78 and 79: i. ii. iii. iv. v. vi. a) b) Educat
Page 80 and 81: tion precautions 580 . There are al
Page 82 and 83: follow the intent 588 . Studies hav
Page 84 and 85: 18. FORMULATING STRATEGIES FOR HAND
Page 86 and 87: 18.2 DEVELOPING A STRATEGY FOR GUID
Page 88 and 89: 1998 (P
Page 90 and 91: HCWs routinely to wear vinyl gloves
Page 92 and 93: quality gloves, reuse, shortage of
Page 94 and 95: • To test for holes, gloves shoul
Page 96 and 97: Figure l.20.2: Blood safety: crucia
Page 98 and 99: Consensus recommendations are that
Page 100 and 101: D. Wash hands with either plain or
Page 102 and 103: 5. SKIN CARE A. B. C. Include infor
Page 107 and 108: PART III. OUTCOME MEASUREMENTS 1. M
Page 109 and 110: 2. HAND HYGIENE AS A QUALITY INDICA
Page 111 and 112: can be seen during routine work. Da
Page 113 and 114: Case study: United Kingdom national
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PART IV. PROMOTING HAND HYGIENE ON
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ated to reinforce its principles (t
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6. PRINCIPLES OF COUNTRYWIDE HAND H
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As many international and national
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debate that resulted in increasing
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23. Lee YL et al. Colonization by S
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Interscience Conference on Antimicr
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122. Vicca AF. Nursing staff worklo
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171. Kauppinen J et al. Hospital wa
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224. Krilov LR et al. Inactivation
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276. Thomas L et al. Development of
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326. Johnson S et al. Prospective,
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34th Interscience Conference on Ant
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423. Kampf G, et al. Influence of a
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474. West DP et al. Evaluation of a
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524. Muto C et al. Hand hygiene rat
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578. Babcock HM et al. An education
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Interscience Conference on Antimicr
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679. Hirschmann H et al. The influe
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729. Martin LS, McDougal JS, Loskos
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Table I.8.1: Basic experimental des
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Table I.9.1: Waterborne pathogens a
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Table I.9.3: Virucidal activity of
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Table I.9.4: Studies comparing the
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Table I.9.6: Studies comparing the
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Table I.14.1: Hand hygiene frequenc
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Table I.14.2: Hand hygiene adherenc
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Table I.15.1: Hand hygiene indicati
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Table I.18.1: Strategies for succes
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Table l.20.1: Possible problems and
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Table I.21.1. Hand hygiene research
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Table I.21.1: Hand hygiene research
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Table I.21.2: Unsolved issues for r
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Table III.2.1: Quality indicators r
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Table V.3.1: Examples of public inf
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Table V.4.1: Examples of national p
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Table V.5.1: The public information
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APPENDIX 1. DEFINITIONS OF HEALTH-C
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APPENDIX 2. HAND AND SKIN SELF-ASSE
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Data in coloured cells can be chang
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NHS NICU n-P NPSA NA NS OPD PACU PA
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AUTHORS: John Boyce Saint Raphael H
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Garance Upham People’s Health Mov
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