Improving Hand Hygiene Among Health-Care Professionals
In health-care settings, hand hygiene is the single most important way to prevent infection
From Dialogue, July 2009
Health-care associated infections affect hundreds of millions of patients worldwide every year. As an unintended result of seeking care, these infections lead to more serious illness, prolonged hospital stays, and induce long-term disability. Not only do they inflict unexpected high costs on patients and their families, they also lead to a massive additional financial burden on the health-care system and — last but not least — contribute to unnecessary patient deaths.
It has been estimated that 220,000 incidents of HAI occur each year, resulting in more than 8,000 deaths in Canada. One in nine patients admitted to Canadian hospitals acquire an infection as a consequence of their hospital stay.
And two decades ago, HAI was the 11th leading cause of death, now it has become the fourth leading cause of death for Canadians.
Most patient deaths and suffering attributable to health-care associated infections can be prevented. Low-cost and simple practices already exist to prevent these infections. Hand hygiene, a very simple action, remains the primary measure to reduce health-care associated infection and the spread of antimicrobial resistance, enhancing patient safety across all settings. Yet compliance with hand hygiene is very low throughout the world.
Failure to apply infection control measures favours the spread of pathogens. This spread may be particularly important during outbreaks, and health-care settings can act as multipliers of disease, with an impact on both hospital and community health. The emergence of life-threatening infections such as severe acute respiratory syndrome (SARS), viral haemorrhagic fevers (Ebola and Marburg viral infections) and the risk of a new influenza pandemic highlight the urgent need for efficient infection control practices in health care.
Making matters more difficult is that most health-care providers believe they are already practising good hand hygiene, states information from the Ontario government’s Just Clean Your Hands campaign. Observational audits from an Ontario study, however, showed a baseline general compliance rate of less than 40%. And yet an increase in hand hygiene adherence of only 20% results in a 40% reduction in the rate of HAIs.
Why does perception and practice differ? Health-care providers generally clean their hands when they are visibly soiled, sticky or gritty or for personal hygiene purposes (i.e. after using the toilet). This habit is frequently learned in early childhood.
Other hand hygiene indications unique to health-care settings are not triggered by the “habit” to clean the hands. Highlighting these indications in health care are needed to create new habits. Examples of actions in health care that do not naturally trigger a need to clean hands include touching a patient, taking a pulse or blood pressure or touching the environment.
While all indications for hand hygiene are important, there are some essential moments in health-care settings where the risk of transmission is greatest and hand hygiene must be performed.
The following are WHO’s recommendations:
Indications for handwashing and hand antisepsis
Wash hands with soap and water when visibly dirty or contaminated with proteinaceous material, or visibly soiled with blood or other body fluids, or if exposure to potential spore-forming organisms is strongly suspected or proven or after using the restroom.
Preferably use an alcohol-based hand rub for routine hand antisepsis in all other clinical situations described in items listed below if hands are not visibly soiled. Alternatively, wash hands with soap and water.
Perform hand hygiene:
a) before and after having direct contact with patients:
b) after removing gloves;
c) before handling an invasive device (regardless of whether or not gloves are used) for patient care;
d) after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings;
e) if moving from a contaminated body site to a clean body site during patient care;
f) after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
Wash hands with either plain or antimicrobial soap and water or rub hands with an alcohol-based formulation before handling medication and preparing food.
When alcohol-based hand rub is already used, do not use antimicrobial soap concomitantly.
To clean hands properly:
- Rub all parts of the hand with an alcohol-based hand rub or soap and running water.
- Pay special attention to fingertips, between fingers, backs of hands and the base of thumbs.
- Keep nails short and clean.
- Remove rings and bracelets.
- Do not wear artificial nails.
- Remove chipped nail polish.
- Make sure that sleeves are pushed up and do not get wet.
- Clean hands for a minimum of 15 seconds.
- Dry hands thoroughly.
- Apply lotion to hands frequently.
Use of Gloves
The use of gloves does not replace the need for hand cleansing by either handrubbing or handwashing.
Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin will occur.
Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient.
When wearing gloves, change or remove gloves during patient care if moving from a contaminated body site to a clean body site within the same patient or to the environment.
Factors influencing adherence to recommended hand hygiene practices
Observed risk factors for poor adherence
- Working in intensive care
- Working during the week (vs. week-end)
- Wearing gowns/gloves
- Automated sink
- Activities with high risk of cross-transmission
- Understaffing or overcrowding
- High number of opportunities for hand hygiene per hour of patient care
- Nursing assistant status (rather than a nurse)
- Physician status (rather than a nurse)
Self-reported factors for poor adherence
- Hand-washing agents cause irritations and dryness
- Sinks are inconveniently located or shortage of sinks
- Lack of soap, paper towel
- Often too busy or insufficient time
- Patient needs take priority
- Hand hygiene interferes with health-care worker–patient relationship
- Low risk of acquiring infection from patients
- Wearing of gloves or belief that glove use obviates the need for hand hygiene
- Lack of knowledge of guidelines and protocols
- Not thinking about it, forgetfulness
- No role model from colleagues or superiors
- Scepticism about the value of hand hygiene
- Disagreement with the recommendations
- Lack of scientific information of definitive impact of improved hand hygiene on health care-associated infection rates