Hand hygiene.pdf

The change in system from the time-consuming handwashing practice to handrub with
an alcohol-based preparation has revolutionized hand hygiene practices, and is now considered
the standard of care 7 . Several studies show a significant increase in hand hygiene
compliance after the introduction of handrub solutions 261,262,359,360,459,524,528,529,592 . Of
note, handrub promotion with an alcohol-based preparation only started to be tested in
intervention studies during the late 1990s. In most of these studies, baseline hand hygiene
compliance was below 50%, and the introduction of handrubs was associated with a significant
improvement in hand hygiene compliance. On the other hand, in the two studies
with baseline compliance equal to or higher than 60% 459,524 , no significant increase was
observed. These findings may suggest that high profile settings may require more specific
targeted strategies to achieve further improvement.
Most studies conducted to test the efficacy of hand hygiene promotion strategies were
multimodal and used a quasi-experimental design, and all but one 535 used internal comparison.
Consequently, the relative efficacy of each of these components remains to be
evaluated.
HCWs necessarily evolve within a group, which functions within an institution. It appears
that possible targets for improvement in hand hygiene behaviour not only include factors
linked to the individual, but also those related to the group and the institution as a
whole 541,552,561 . Examples of possible targets for hand hygiene promotion at the group
level include education and performance feedback on hand hygiene adherence, efforts to
prevent high workloads (i.e. downsizing and understaffing), and encouragement and role
modelling from key HCWs in the unit. At the institutional level, targets for improvement are
the lack of written guidelines, available or suitable hand hygiene agents, skin care promotion/agents
or hand hygiene facilities, lack of culture or tradition of adherence, and the lack
of administrative leadership, sanctions, rewards or support. Enhancing individual and institutional
attitudes regarding the feasibility of making changes (self-efficacy), obtaining active
participation at both levels, and promoting an institutional safety climate all represent major
challenges that go well beyond the current perception of the infection control professional’s
usual role.
Table I.18.1 reviews published strategies for the promotion of hand hygiene in hospitals
and indicates whether these require education, motivation or system change. Some of the
strategies may be unnecessary in certain circumstances, but may be helpful in others. In particular,
changing the hand hygiene agent could be beneficial in institutions or hospital wards
with a high workload and a high demand for hand hygiene when alcohol-based handrub
is not available 120,123,485,594 . A change in the recommended hand hygiene agent could be
deleterious, however, if introduced during winter in the northern hemisphere at a time of
higher hand skin irritability and, in particular, if not accompanied by skin care promotion
and availability of protective cream or lotion.
Whether increased education, individual reinforcement technique, appropriate rewarding,
administrative sanction, enhanced self-participation, active involvement of a larger
number of organizational leaders, enhanced perception of health threat, self-efficacy, and
perceived social pressure 537,541,552,595,596 , or combinations of these factors would improve
HCWs’ adherence to hand hygiene needs more research. Ultimately, adherence to recommended
hand hygiene practices should become part of a culture of patient safety where a
set of interdependent elements of quality interact to achieve the shared objective 597 .
It is important to note, however, that the strategies proposed in Table I.18.1 reflect studies
conducted mainly in developed countries. Whether their results can be generalized to different
backgrounds for implementation purposes still needs further research.