Infection prevention in hospitals: The importance of hand hygiene

Hand hygiene is described by many health care workers as the single most important tool in preventing the spread of health care-associated infections between patients.

According to WHO, there are few definitive data on the patient-care activities that are most likely to transmit bacteria to health care worker (HCW) hands, but there have been several studies that identified many possibilities. Although bacteria have been found on HCW hands after activities such as wound care, intravascular catheter care, respiratory tract care and handling patient secretions as expected, bacteria also have been found after so-called “clean” contact, such as taking a patient’s pulse, temperature or blood pressure.

Organisms found on HCW hands after such patient contact range from Klebsiella spp., Staphylococcus aureus, Clostridium difficile, MRSA and gram-negative bacteria. However, direct patient contact is not the only way HCW hands can be contaminated. HCWs can acquire bacteria on their hands by touching contaminated surfaces in the patient environment and by touching a contaminated chart at the nurses’ station, according to the literature.

“When we look at all of the things that we can do to prevent infections in the hospital, one of the most important things about hand hygiene is that it works for so many different types of organisms, and you get a lot of bang for the buck,” Michael Edmond, MD, MPH, the Richard P. Wenzel professor of internal medicine in the division of infectious diseases at Virginia Commonwealth University, told Infectious Diseases in Children. “The issue is that you have to practice it at a high level of compliance for it to work. There are so many opportunities for hand hygiene, and it is difficult to get to a level of compliance where we’re able to make changes to infection rates.

Proven benefits

In the mid-1800s, the concept of hand hygiene was first introduced by a Hungarian physician named Ignaz P. Semmelweis, who found that when physicians washed their hands before delivering babies, it prevented deaths in postpartum women, according to Connie Price, MD, associate professor of medicine at the University of Colorado Denver. Although Semmelweis was initially ridiculed for this suggestion, it was recognized that he was correct.

“After centuries of knowledge, it is now known that Semmelweis was right, and that hand-washing is an effective way to prevent HAIs,” Price, also chief of infectious diseases at Denver Health Medical Center, told Infectious Diseases in Children. “All of the technologies we have, all of the other intricate tools we use to prevent HAIs can easily be nullified if HCWs don’t wash their hands.”

Various organizations, including the CDC and WHO, have published guidelines on appropriate hand hygiene practices for HCWs.

The five moments of hand hygiene outlined by WHO are: Before patient contact; before aseptic task; after bodily fluid exposure; after patient contact; and after contact with patient surroundings.

Despite these guidelines, as well as the Joint Commission requiring some type of monitoring or quality assessment protocols for hand hygiene in hospitals, compliance rates are far from where they should be.

“There are multiple papers that show adherence to hand hygiene, according to the WHO guidelines, is usually around 50% to 60%,” Elaine Larson, PhD, RN, Anna C. Maxwell professor of nursing research and associate dean for research at Columbia University School of Nursing, told Infectious Diseases in Children.

Lack of compliance

“There is a great awareness about hand hygiene among HCWs,” Emily Landon, MD, assistant professor in the section of infectious diseases at The University of Chicago department of medicine and medical director of antimicrobial stewardship and infection control at the University of Chicago Medical Center, told Infectious Diseases in Children. “Everyone knows the importance of hand hygiene, and everyone wants to perform hand hygiene.”

Edmond said one potential reason for low compliance is that the target is invisible: HCWs do not realize they are carrying pathogens on their hands because they cannot see them. Another reason is they cannot link their contact with a patient to an infection that may result days or even months later.

In addition, the risk to the HCWs from not performing hand hygiene is low, Edmond said. It is unlikely that they will get an infection if they do not wash their hands. The risk for infecting a patient from one episode of noncompliance is small. However, the patient bears the cumulative risk of all episodes of noncompliance, and there are a lot of issues regarding the perception of patient risk.

Changing habits

Many studies have shown that the principal reason HCWs do not wash their hands enough is because they are too busy, or there are not enough hand rub dispensers available, Landon said.

“HCWs are very often overwhelmed by thinking of other things, particularly the status of their patients, and they never develop a habit of hand hygiene,” Landon said. “If hand hygiene was something you needed to remember before each patient, it would be a huge flub. It’s something that needs to be done as a habit, without even thinking about it. The problem is that it’s difficult to create that habit or enforce it among HCWs.”

Edmond agreed and said the main problem associated with a lack of compliance is that humans are not naturally “hardwired” to perform hand hygiene in the absence of sensing a substance on their hands.

Larson said for some HCWs, it is ingrained, and they do perform hand hygiene almost exactly according to the WHO’s “Five Moments for Hand Hygiene,” which is currently the standard hand hygiene guideline used by most health care facilities. However, for some, adoption of these guidelines means rethinking current habits.

Objective monitoring

The gold standard in monitoring hand hygiene compliance is direct observation, Landon said, usually by infection control practitioners or a dedicated person such as the nursing manager of a group.

Hand hygiene compliance increases dramatically when these observers, who are usually well known to the staff, are circulating in the unit, Landon said. Then compliance rates decline when those people are no longer around.

In one study, Landon and colleagues hired a new student for hand hygiene observation in the same unit that a well-known practitioner had recently observed.

“We found that the practitioner observed close to 70% compliance with hand hygiene and the student observed close to 30% compliance,” Landon said. “The bottom line is that there is a big discrepancy between what is observed by a brand new observer and by someone well known to the unit.”

It is the classic Hawthorne effect, Edmond said. People change their behavior when they know they are being watched. In addition, another pitfall of direct observation is that it is difficult to observe a significant fraction of the total number of hand hygiene opportunities, he said, which in any given hospital on any given day is huge.

Automated technologies

Research is underway to identify more objective and reliable methods to measure compliance. There are many potential systems to accomplish this.

One method is to have HCWs wear a wristband or badge that gives reminders to do hand hygiene. The HCW would receive a printout of their individual compliance rate in real time. An individualized method such as this would be the “holy grail,” Landon said, because it provides individual feedback. However, in a recent study of a badge system utilizing radiofrequency identification tracking, the researchers found that the accuracy for identifying hand hygiene events in a real-life clinical setting was only 52.4%.

Another tool being evaluated is a counter that tracks how many times a soap or hand sanitizer dispenser is used. Larson said a group monitoring system such as this is more in line with what is trying to be accomplished: creating an entire culture of patient safety so that everyone feels responsible.

These systems are still investigational, however, and one of the drawbacks is that they require new technological platforms.

“There are many ways the technology can be used, and it can be effective, but a lot of work still needs to be done on these new electronic methods,” Edmond said. “The bottom line is that we don’t have a great, easy, inexpensive way to measure hand hygiene right now.”

Ensuring accountability

Monitoring hand hygiene is only the first step. Policies also must be in place to hold people accountable for hand hygiene.

The Joint Commission recommends an approach that includes direct observation by different observers on a rotating basis, Landon said. The approach also includes an accountability piece: If hand hygiene has not improved, the offender receives warnings and undergoes other reinforcements such as online classes or discussions with an infection control committee member to encourage them to wash their hands. The system also utilizes a human resources disciplinary system: After enough warnings, people can lose their jobs for not washing their hands.

Price said the Agency for Healthcare Research and Quality and the CDC have produced materials to incorporate infection prevention into medical education, and many HCWs are required to regularly retake an infection control test module that incorporates in-depth information on hand hygiene.

“Hand hygiene is more important than ever with the rising threat of multidrug-resistant organisms,” Price said. “Antibiotic stewardship programs are powerful, but they’re not going to be effective if you don’t have good, solid infection control like hand hygiene.”

Behavioral science

Most hospitals have installed dispensers of hand sanitizer throughout the units to make it easier for HCWs to clean their hands. Larson said this is important because hand sanitizer works faster and is better for most things.

“I naively thought that having this easy-to-use product so accessible would take care of the hand hygiene compliance,” Larson said. “It’s a facilitator of hand hygiene, and it’s an important barrier if it’s not available. It’s necessary, but it’s not enough.”

Any hand hygiene program will need to have a long-term benefit, Landon said. Many have a definite short-term effect at changing behaviors, such as signs on doors that remind HCWs about hand hygiene. But after a certain amount of time, behavior reverts to old patterns because the signs are no longer new.

“The longer I do infection control, the more I think infection control is a behavioral science,” Edmond said. “It’s about getting people to do these certain things that we need them to do, and to get that to happen, we need to remove all the barriers to get them to do the right thing. If we can do things that nudge them to do hand hygiene, then we’ve accomplished our goal.” — by Emily Shafer.