Hand hygiene.pdf

18. FORMULATING STRATEGIES FOR HAND HYGIENE
PROMOTION
18.1 ELEMENTS OF PROMOTION STRATEGIES
Targets for the promotion of hand hygiene are derived from studies assessing risk factors
for non-adherence, reported reasons for the lack of adherence to recommendations, and
additional factors perceived as important to facilitate appropriate HCW behaviour (see also
Part I, Section 14.3). Although some factors cannot be modified (Table I.18.1), others are
definitely amenable to change. Based on the studies and successful experiences in some
institutions described below, it appears that strategies to improve adherence to hand hygiene
practices should be multimodal and multidisciplinary.
The last 20 years have shown an increasing interest in the subject and many intervention
studies aimed at identifying effective strategies to promote hand hygiene
have been conducted 152,261,262,359,360,459,489,504,507,508,511,522,524,526,528-531,535,536,568,569,5
91,592 . These studies differed very much in their duration and intervention approach. In
addition, the outcome measure of hand hygiene compliance varied in terms of the
definition of a hand hygiene opportunity and assessment of hand hygiene by means of
direct observation 152,261,262,359,360,426,459,504,507,508,511,522,524,528-530 or consumption of
hand hygiene products 261,262,360,535,568,569,591,592 , making comparison difficult, if not
impossible. Despite different methodologies, most interventions have been associated
with an increase in hand hygiene compliance, but a sustainable improvement
has rarely been documented 262 . Most studies used multiple strategies, which
included: HCWs’ education 261,262,359,360,459,504,507,508,511,518,524,526,528-530,535,591,592 ,
feedback performance 261,262,359,360,504,507,508,511,518,522,524,526,528-530,535 , reminders
261,262,359,504,507,508,522,524,528-530,592 , use of automated sinks, and/or introduction of an
alcohol-based handrub 359,360,524,528-530,591-593 .
Lack of knowledge of guidelines for hand hygiene and unawareness of hand hygiene
indications during daily patient care and potential risks of transmission of microorganisms
to patients constitute barriers to hand hygiene compliance. Lack of awareness of the very
low average adherence rate to hand hygiene of most HCWs and lack of knowledge about
the appropriateness, efficacy and understanding of the use of hand hygiene and skin care
protection agents contribute to poor hand hygiene performance 561 .To overcome these
barriers, education has been one of the cornerstones of improvement in hand hygiene
practices 7,261,262,359,360,459,504,507,508,511,518,524,526,528-531,535,536,572,591,592 . However, lack of
knowledge of infection control measures after training has been repeatedly shown 552 .
Audits of hand hygiene practices (see also Part III, Section 1.1) and feedback performance
have comprised several multifaceted promotion campaigns and are valued as one of
the most effective strategies 561 .Two studies have reported a very positive impact on hand
hygiene due to feedback performance 507,518 . Conversely, these results should be viewed
with caution. In one study 507 , no statistical evaluation is provided and the very low number
of observed opportunities during the three surveys precludes further conclusions. Tibballs
and colleagues 518 showed an extraordinary improvement after feedback of hand hygiene
practices. One of the caveats in this study is that baseline compliance was obtained by
covert observation and the subsequent survey was overtly performed, which might have
favoured better results 263 .