Bennett & Brachman's Hospital Infections, 5th Edition

3

Hand Hygiene

Didier Pittet

Benedetta Allegranzi

Hugo Sax

History of Hand Hygiene

Handwashing with soap and water has been considered a measure of personal hygiene for centuries [1,2], but the link between handwashing and the spread of disease was established only in the last 200 years. In the mid-1800s, decades before the discoveries of Pasteur and Lister, studies by Ignaz Semmelweis in Vienna and Oliver Wendell Holmes in Boston established that hospital-acquired diseases were transmitted via the hands of healthcare workers (HCWs). In 1847, Semmelweiss was appointed as a house officer in one of the two obstetric clinics located at the University of Vienna Allgemeine Krankenhaus (General Hospital). He observed that maternal mortality rates, mostly due to puerperal fever, were substantially higher in one clinic compared to the other (16% vs. 7%) [3]. He also noted that physicians and medical students often went directly to the delivery suite after performing autopsies and had a disagreeable odor on their hands despite handwashing with soap and water before entering the clinic. He hypothesized that “cadaverous particles” were transmitted via the hands of students and physicians and caused puerperal fever. As a consequence, Semmelweis recommended that hands be scrubbed in a chlorinated lime solution before every patient contact and particularly after leaving the autopsy room. Following the implementation of this measure, the mortality rate dropped dramatically to 3% in the clinic most affected.

This intervention represents the first evidence that cleansing heavily contaminated hands with an antiseptic agent can reduce nosocomial transmission of germs more effectively than handwashing with plain soap and water. Unfortunately, both Holmes and Semmelweis failed to observe a sustained change in their colleagues' be-havior.

A prospective controlled trial conducted in a hospital nursery [4] and investigations conducted during the past 40 years have confirmed the important role that contaminated HCWs' hands play in the transmission of healthcare-associated infection (HAI) pathogens [5].

The 1980s represented a landmark in the evolution of concepts of hand hygiene in health care. The first national hand hygiene guidelines were published in the 1980s [6,7,8], followed by several others in more recent years in different countries.

In 1995 and 1996, the U.S. Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended that either antimicrobial soap or a waterless antiseptic agent be used for cleansing hands upon leaving the rooms of patients with multidrug-resistant pathogens [9,10]. More recently, the CDC/HICPAC guidelines issued in 2002 [11] and the current advanced draft of the World Health Organization (WHO) Guidelines on Hand Hygiene in Healthcare [5] have defined alcohol-based handrubbing, where available, as the standard of care for hand hygiene practices in healthcare settings, whereas handwashing is reserved for particular situations only [5].

Definitions

Hand hygiene during healthcare delivery can be performed either by handwashing or by handrubbing. The purpose of performing hand hygiene for routine patient care is to remove microbial contamination acquired by recent contact with infected or colonized patients or with environmental sources and, in some instances, to remove organic matter from the hands.

Standard handwashing with plain soap and water removes lipid and adhering dirt, soil, and various organic substances from the hands. Plain soap has minimal antimicrobial activity but after 30 seconds can reduce counts by 1.8–2.8 log₁₀ [1]. In several studies, however, handwashing

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with plain soap failed to remove pathogens from HCW's hands [12,13,14].

Hygienic hand antisepsis is significantly more efficient than standard handwashing and can be performed either by washing with an antimicrobial soap or a detergent and water (antiseptic handwashing) or by handrubbing with antiseptic preparations (antiseptic handrubbing). Antiseptic handrubs are available as different formulations (liquid, gels, foams) and bypass the need for an exogenous source of water and towels or other hand-drying devices.

Indications for performing hand hygiene and for opting for handwashing rather than handrubbing are discussed in the following sections and listed in Table 3-1.

TABLE 3-1 INDICATIONS FOR HANDWASHING AND HAND ANTISEPSIS

Adapted from World Health Organization. WHO Guidelines for Hand Hygiene in Health Care (Advanced Draft). Geneva: World Health Organization, 2006 (http://www.who.int/patientsafety/information_centre/Last_April_versionHH_Guidelines%5b3%5d.pdf) accessed 19 July 2006. Washing hands with soap and water when visibly dirty or contaminated with proteinaceous material, visibly soiled with blood or other body fluids, or if exposure to potential spore-forming organisms is strongly suspected or proven (IB) or after using the restroom (II). Preferably use an alcohol-based handrub for routine hand antisepsis in all other clinical situations described in items (a) to (f) listed if hands are not visibly soiled (IA). Alternatively, wash hands with soap and water (IB). Perform hand hygiene: 1. Before and after having direct contact with patients (IB). 2. After removing gloves (IB). 3. Before handling an invasive device for patient care regardless of whether or not gloves are used (IB). 4. After contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings (IA). 5. If moving from a contaminated body site to a clean body site during patient care (IB); 6. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (IB). Wash hands with either plain or antimicrobial soap and water or rub hands with an alcohol-based formulation before handling medication or preparing food (IB). When alcohol-based handrub is already used, do not use antimicrobial soap concomitantly (II).

Model of Hand Transmission of Microorganisms in Health Care

A clear understanding of the process of hand transmission is critical to successful education strategies, assessment of HCWs' hand hygiene performance, and research. According to existing scientific evidence [5], a model of hand transmission has been proposed and serves as a basis for the recently reviewed recommendations on indications for hand hygiene action [5].

Transmission of HAI pathogens from one patient to another or within the same patient from one body site to another via HCWs' hands requires five sequential steps described in more detail below and illustrated in Figure 3-1.

Step 1: Organisms Present on Patient Skin or the Inanimate Environment

Both the patient's skin [12,15,16,17,18,19,20,21] and the inanimate environment [13,21,22,23,24] harbor large amounts of germs including multiresistant bacteria, fungi, and viruses. Of importance, HAI pathogens can be recovered not only from infected or draining wounds but also from frequently colonized areas of normal, intact patient skin. Exogenous and endogenous factors, such as exposure to antibiotics and medical devices, host immunity deficiency and patient comorbidities as well as the frequency and efficacy of hand cleansing by HCWs determine the type of skin flora and its burden. The microbial load on surfaces in the hospital environment will equally vary in an unpredictable way due to type of surface and environmental cleaning, patient characteristics, hand hygiene, and humidity.

Step 2: Organism Transfer on Healthcare Workers' Hands

In addition to resident flora, hand skin acquires transient flora by exposure to colonized objects, inanimate surfaces, and patients. Contamination of HCWs' hands before and after direct patient contact, wound care, intravascular catheter care, respiratory tract care, and handling patient secretions [25] revealed that the number of bacteria recovered ranged from 0 to 300 colony-forming units. Hand colonization occurs also following “clean procedures” or touching intact areas of skin of hospitalized patients [13,18,24,26]. Furthermore, gloves do not provide complete protection against hand contamination [27,28,29,30].

Step 3: Organism Survival on Hands

Hand colonization with commensal flora and with potential pathogens progressively increases during patient care due to germ capacity to survive on skin [25,31]. Several studies have shown the ability of microorganisms to survive on hands for differing times [32,33,34,35]. For example, according to Noskin et al., both Enterococcus faecalis and vancomycin-resistant E. faecium survived for at least 60 minutes on gloved and ungloved fingertips [36]. Studies by Ansari et al. using rotavirus, rhinovirus, and human parainfluenza virus 3 showed survival up to 60 minutes [37,38].

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Step 4: Defective Hand Hygiene Results in Hands Remaining Contaminated

When HCWs fail to clean their hands between touching different patients or during the sequence of patient care, particularly when hands move from a microbiologically contaminated to a clean body site in the same patient, microbial transfer is likely to occur. Adequate and timely hand hygiene technique is essential for effective removal of contamination and to prevent persistent colonization.

Wearing rings and artificial fingernails increases the frequency of hand contamination with potential HAI pathogens, even after use of either soap or alcohol-based hand gel [39,40] and has been associated with HAI outbreaks [41].

Step 5: Contaminated Hands Cross-Transmit Organisms

Failure to practice hand hygiene between sequential hand-surface exposures results in HCWs' hands acting as organism carriers ready to spread potentially harmful pathogens onto another surface. Once deposited on patients, the cross-transmitted organisms will establish either a carrier state or lead directly to infection (Figure 3-1).

Figure 3-1 Model for hand transmission of microbial pathogens. (Reproduced with permissionfrom Pittet D, Allegrenzi B, Sax H, Dharan S., Pessoa-Silva CL, Donaldson L, Boyce JM, WHO Global Patient Safety Challenge, World Alliance for Patient Safety. Evidence-based model for hand transmission during patient care and the role of improved practices.Lancet Infect Dis 2006; 6:641–652.)

Of importance, pathogen transfer also can occur within the same patient from a colonized area to a clean body site or onto an invasive medical device. Given that most HAIs are of endogenous nature, this latter pathway of transmission by HCWs' hands is of the utmost etiologic importance.

Indications for Hand Hygiene During HealthCare

Effective hand hygiene should remove transient flora on HCWs' hands at critical moments during care activity with the clear objective to prevent cross-transmission of potentially harmful organisms and infection. A set of indications for hand hygiene has been established according to scientific evidence and is congruent with the model of transmission (as noted previously). These indications are listed in the most recent international guidelines and weighed according to supporting evidence (Table 3-1) [5]. The first indications on the list (i.e., before and after having direct

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contact with a patient) are easy to remember for HCWs because they are linked to approaching or leaving the patient. Other indications, more difficult to identify, are linked to specific tasks and occur mostly during a care sequence in the same patient (i.e., before handling an invasive device or after a task associated with the risk of exposure to body fluids). According to the model of transmission, hand hygiene before a patient contact or an invasive procedure is aimed at protecting the patient. In contrast, hand hygiene after tasks or contact with patients and their immediate surroundings serves to protect the HCW against colonization and infection and to prevent germ spread to the environment. Intriguingly, HCWs more often comply with the indication after a patient contact or after a care task.

For practical purposes, it is important to recognize that ≥2 of the listed indications might occur simultaneously during a sequence of care requiring only a single hand hygiene action. The guidelines also describe optimal techniques for handrubbing and handwashing and specify that the latter be reserved only for situations when hands are visibly soiled and transmission of spores is strongly suspected or proven and after using the restroom [5] (Table 3-1).

Hand hygiene should be performed after glove removal because wearing gloves does not completely prevent hand colonization [31] and/or contamination. Moreover, hand hygiene should be performed when an indication occurs, regardless of whether gloves are worn or not [5,11].

Properties of Hand Antisepsis Agents

Antiseptic agents (both soap and handrubs) contain an antimicrobial substance, which reduces or inhibits the growth of microorganisms on living tissues. The most popular agents are briefly described next (Table 3-2).

Considering antimicrobial activity, alcohols have the broadest antimicrobial spectrum compared to other agents, with excellent in vitro and in vivo activity against Gram-positive and Gram-negative vegetative bacteria (including multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci),Mycobacterium tuberculosis, and a variety of fungi [42,43,44,45,46,47,48,49,50]. Mycobacteria and fungi also are killed by iodophors and less effectively by chlorhexidine, chloroxylenol, or hexachlorophene. Most enveloped (lipophilic) viruses (e.g., herpes simplex virus, human immunodeficiency virus, influenza virus, respiratory syncytial virus, and vaccinia virus) are susceptible to alcohols, chlorhexidine, and iodophors [42,51,52,53,54,55,56,57,58,59]. Other enveloped viruses (hepatitis B virus and probably hepatitis C virus) are somewhat less susceptible to alcohols but are killed by concentrations as high as 60–70% (v/v) [60]. In some in vivo studies, alcohols showed some activity also against a number of non-enveloped viruses (rotavirus, adenovirus, rhinovirus, hepatitis A virus, and enteroviruses) [61,62,63,64,65]. In general, ethanol has stronger activity against viruses than isopropanol [66]. Iodophors and, to a minor extent, chlorhexidine also are active against some non-enveloped viruses. None of the listed antiseptic agents has an activity against bacterial spores or protozoan oocysts. Iodophors are only slightly sporicidal but at higher concentrations than the ones used in antiseptics [67].

Alcohols are the most frequently used antimicrobial component of handrubs. Alcohol-based handrubs are considered the most effective antiseptic agents for hand hygiene, and they generally contain either ethanol, isopropanol or n-propanol or a combination of two of these products. Alcohol solutions containing 60–80% (v/v) alcohol are most effective with higher concentrations being less potent [43,44]. In all published studies, alcohols were more effective than plain soap; furthermore, in the vast majority of trials, they reduced bacterial counts on hands to a greater extent than washing hands with soaps or detergents containing hexachlorophene, povidone-iodine, 4% chlorhexidine, or triclosan [68].

Chlorhexidine gluconate has been incorporated into a number of hand hygiene preparations. Aqueous or detergent formulations containing 0.5%, 0.75%, or 1% chlorhexidine are more effective than plain soap but less effective than antiseptic detergent preparations containing 2% and 4% chlorhexidine gluconate [69,70]. Chlorhexidine's immediate antimicrobial activity is slower than that of alcohols, but it has significant residual activity [69,70,71,72,73,74,75,76].

Iodophors are composed of elemental iodine, iodide, or triiodide, and a polymer carrier of high molecular weight, such as polyvinyl pyrrolidone (povidone) and ethoxylated nonionic detergents (poloxamers) [55,77]. Their persistent antimicrobial activity is controversial. Most iodophor preparations used for hand hygiene contain 7.5–10.0% povidone-iodine.

Chloroxylenol has been widely used in antimicrobial soaps and as a preservative in cosmetics and other products. It has good in vitro activity against Gram-positive organisms and fair activity against Gram-negative bacteria, mycobacteria, and some viruses [1,78,79]; in particular, the activity against Pseudomonas aeruginosa is limited. Chloroxylenol is considered to be less rapidly active than chlorhexidine gluconate or iodophors, and its residual activity is less pronounced than that of chlorhexidine [78,79].

Hexachlorophene is a bisphenol contained in emulsions used for hygienic handwashing and patient bathing. It has residual activity for several hours after use and a cumulative effect [1,80,81,82]. Because of its high rates of dermal absorption and subsequent toxic effects, including neurotoxicity [83], the agent is classified by the U.S. Food and Drug Administration (FDA) as not safe and effective for use as an antiseptic agent for handwashing and has been banned worldwide [66,84,85].

Quaternary ammonium compounds belong to a large group; alkyl benzalkonium chlorides have been the most

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widely used as antiseptics. They are primarily bacteriostatic and fungistatic, though microbicidal at high concentrations against some organisms [1]. They are more active against Gram-positive bacteria than against Gram-negative bacilli and have relatively weak activity against mycobacteria and fungi and stronger activity against lipophilic viruses.

TABLE 3-2 PREPARATIONS FOR HAND HYGIENE

Agent Gram + Bacteria Gram - Bacteria Mycobacteria Fungi Enveloped Virus Non-enveloped Virus Spores Speed of Action Residual Activity Use HR, handrubbing; HW, handwashing Activity: + + + excellent; + + good, but does not include the entire bacterial spectrum; + fair; ± controversial; - no activity a Bacteriostatic. b In concentrations used in antiseptics, iodophors are not sporicidal. c Bacteriostatic, fungistatic, microbicidal at high concentrations. d Mostly bacteriostatic. e Activity against Candida spp., but little activity against filamentous fungi. Alcohols + + + + + + + + + + + + + + + - Fast No HR Chlorhexidine + + + + + + + + + + - Intermediate Yes HR, HW Chloroxylenol + + + + + + + ± - Slow Contradictory HW Hexachlorophenea + + + + + + ? ? - Slow Yes HW, but not recommended Iodophors + + + + + + + + + + + + + + ±b Intermediate Contradictory HW Quaternary ammonium compoundsc + + + ± ± + ? - Slow No HR, HW; seldom; + alcohols Triclosand + + + + + ± ±e ? ? - Intermediate Yes HW; seldom

Triclosan is a nonionic, colorless substance that has antimicrobial activity at concentrations ranging from 0.2% to 2% but tends to be bacteriostatic [1]. Like chlorhexidine, triclosan has persistent activity on the skin. According to the FDA, available data are insufficient to classify it as safe and effective for hand antisepsis [84].

Methods to Evaluate the Antimicrobial Efficacy of Antiseptic Agents

Every new formulation for hand antisepsis should be tested for its antimicrobial efficacy to demonstrate that it has superior efficacy over normal soap or meets an agreed performance standard. The most appropriate method is to artificially contaminate volunteers' hands with the test organism before applying the test formulation. In Europe, the most commonly used test methods (EN 1499 [86] for antiseptic soaps and EN 1500 [87] for handrubs) are those of the European Committee for Standardization (CEN). These use a randomized, crossover design and compare the product with a standardized reference agent. The EN 1499 [86] norm requires that the mean log₁₀ reduction of microbial hand contamination by the antiseptic soap be significantly higher than that obtained with the control (soft soap). For the EN 1500, the efficacy of the tested handrub should not be significantly lower than that of the reference alcohol-based rub (isopropyl alcohol or isopropanol 60% volume).

In the United States, antiseptics are regulated by the FDA [84] which refers to the standards of the American Society for Testing and Materials (ASTM). The most frequently used method for testing handwashing and handrubbing agents is the ASTM E-1174 [88]. Criteria for efficacy are a 2-log₁₀ reduction of the indicator organism on each hand within 5 minutes after the first use and a 3-log₁₀ reduction within 5 minutes after the tenth use.

Shortcomings of current test methods are discussed in detail elsewhere [5].

Skin Reactions

The tolerability of hand hygiene products is a major factor that influences acceptance and ultimate usage by HCWs and is a key determinant to the success of hand hygiene promotion [89].

Two major types of skin reactions are associated with hand hygiene: irritant contact dermatitis and allergic contact dermatitis.

Irritant Contact Dermatitis

The first reaction type is the most common and includes symptoms such as dryness, burning sensation, itching, skin that feels “rough,” erythema, scaling, cracking, and bleeding. Frequent and repeated use of hand hygiene products, particularly soaps and other detergents, is an important cause of chronic irritant contact dermatitis among HCWs [90]. In one study, approximately 25% of nurses reported symptoms or signs of dermatitis on their hands, but 85% gave a history of skin problems [91]. Skin that is damaged by repeated exposure to detergents may be more susceptible to irritation by all types of hand antiseptic formulations [92]. Hot water, incomplete drying of hands, and the quality of paper towels can contribute to dermatitis. Low relative humidity associated with failure to use supplementary hand lotion or cream contributes to dermatitis with both hand rubbing and washing [93,94].

Shearing forces when wearing or removing gloves and allergy to latex proteins also are risk factors for hand dermatitis among HCWs [95]. Routinely washing hands with soap and water immediately before or after using an alcohol-based formulation not only is unnecessary but also may lead to dermatitis. Additionally, frequent glove use and donning gloves while hands are still wet can increase the risk of skin irritation.

Antimicrobial soaps may cause irritation due to the antimicrobial agent or to other ingredients of the formulation. Several studies have demonstrated that alcohol-based preparations are better tolerated and associated with better skin condition when compared with either plain or antiseptic hand products [89]. Irritant contact dermatitis is more commonly reported with iodophors [96] and less frequently with chlorhexidine, chloroxylenol, triclosan, or alcohol-based products. The variable potential of detergents to cause skin irritation can be reduced by adding emollients and humectants.

Allergic Contact Dermatitis

Allergic contact dermatitis is rare and results from an allergy to an ingredient in the hand hygiene product; clinical symptoms can be mild and localized or severe, such as anaphylaxis. Allergic reactions to products applied to the skin (contact allergy) can present as a delayed type of reaction (allergic contact dermatitis) or less commonly as an immediate reaction (contact urticaria). The most common causes of contact allergies are fragrances and preservatives with emulsifiers being less common triggers [97,98,99,100]. Liquid soaps, hand lotion, ointments, or creams used by HCWs can contain ingredients causing contact allergies [98,99].

Allergic reactions to antiseptic agents including quaternary ammonium compounds, iodine or iodophors, chlorhexidine, triclosan, chloroxylenol, and alcohols and possible toxicity in relation to dermal absorption of products have been reported [89]. Allergic contact dermatitis

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due to alcohol-based handrubs is very uncommon, however, and could represent true allergy to the alcohol, to an impurity or aldehyde metabolite, or to another product constituent [89,97,101]. There are few reports of allergic dermatitis resulting from contact with ethanol [102,103,104] and only one report of ethanol-related contact urticaria syndrome [105]. More recently, Cimiotti et al. reported adverse reactions, mostly reversible, associated with an alcohol-based handrub preparation [106].

There are three primary strategies to minimize hand hygiene-related irritant contact dermatitis among HCWs: selection of less irritating hand hygiene products, education regarding proper skin care management, and routine use of moisturizing skin care products.

Monitoring Hand Hygiene Practices and Determinants of Compliance

Monitoring hand hygiene performance is an activity of crucial importance to assess baseline compliance by HCWs, provide feedback to HCWs, evaluate the impact of promotion interventions, investigate outbreaks, and answer research questions [107,108,109,110,111,112,113,114,115,116,117].

Hand hygiene practices during routine healthcare delivery can be evaluated directly or indirectly. Direct methods include observation, patient assessment, and self-reports. Direct observation by trained and validated observers is regarded as the gold standard because it quantifies the need for hand hygiene and the actual performance. To calculate the compliance rate, the number of hand hygiene actions performed by HCWs is divided by the number of opportunities for hand hygiene. The method should respect basic epidemiological principles (e.g., sample size calculation, exclusion of selection, observer, and observation bias). Eventually, adjustment for confounders (e.g., professional category or healthcare setting) could be needed.

Indirect methods include monitoring consumption of products (e.g., soap, handrub, and paper towels) and electronic monitoring of the use of wash basins or handrub dispensers. These methods can be attractive as less time consuming and resource demanding than direct observation. Lack of a quantification of the need for hand hygiene can partially be surrogated by relating consumption to patient-days or workload measures [118] or estimating the required amount using a computerized database of nursing activities [119]. Some studies [107,120,121] have shown that the consumption of products used for hand hygiene correlated with observed hand hygiene compliance; others established no correlation [122]. Thus, the use of this measure as a surrogate for monitoring hand hygiene practices deserves further validation.

Recent epidemiologic investigations on HCWs' compliance with hand hygiene have revealed key findings. Adherence has been unacceptably poor with mean baseline rates ranging from 5% to 81% and an overall average of about 40% (reviewed in detail in [5]). In the largest survey conducted so far [123], 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 (Figure 3-2), 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 (Table 3-3). Moreover, perceived barriers to adherence with hand hygiene guidelines have been assessed or quantified in observational studies. Among others, they 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, and high workload and understaffing (Table 3-3).

Figure 3-2 Relation between opportunities for hand hygiene and compliance across hospital wards. (Modified with permission from Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999; 130:126–130.)

Recent studies have confirmed an inverse relation between intensity of patient care and adherence to hand hygiene (Figure 3-3) [124,125,126]. Thus, time required for traditional handwashing could make optimal compliance with earlier guidelines unrealistic. The system change from time-consuming handwashing to handrub with an alcohol-based preparation has revolutionized hand hygiene practices and now is considered the standard of care [5,127].

Strategies to Promote Hand Hygiene

HCW education is an inherent component of the work of the infection control team. However, it is now recognized that education alone may not be sufficient to achieve hand

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hygiene improvement. HCWs' behavioral attitudes toward compliance with recommended practices are extremely complex and multifactorial [128,129,130,131,132], and experts agree that a successful program must be multidisciplinary and multifaceted to counteract most reasons for poor compliance [115,131].

TABLE 3-3 MAIN FACTORS INFLUENCING ADHERENCE TO HAND HYGIENE PRACTICES

Individual level · Lack of education or experience · Being a physician, compared to other health-care professionals · Lack of knowledge of guidelines · Being a refractory noncomplier · Skin irritation by hand hygiene agents Group level · Lack of education or lack of performance feedback · Working in critical care or in high workload conditions · Downsizing or understaffing · Lack of encouragement or role model from key staff Institutional level · Lack of written guidelines · Lack of suitable hand hygiene agents · Lack of skin-care promotion or agents · Lack of culture or tradition of compliance · Lack of administrative leadership, sanctions, rewards, or support Governmental level · Lack of awareness and commitment regarding the importance of health care-associated infection · Lack of specific regulations and policies on prevention of healthcare-associated infection · Lack of national guidelines on hand hygiene in health care · Lack of promotion of national or regional campaigns to improve hand hygiene in health care · Insufficient allocation of financial resources for this purpose

Figure 3-3 Relation between the number of opportunities for hand hygiene and compliance. (Modified with permission from Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999; 130:126–130.)

Several studies showed a significant increase in hand hygiene compliance after the introduction of handrubs [107,113,120,121,123,133,134,135,136,137,138,139,140]. Moreover, availability of handrub dispensers at the point of care or individual pocket dispensers is now considered the standard of care [5,127].

Table 3-4 presents published strategies for the promotion of hand hygiene in hospitals. Some of the strategies could be unnecessary in certain settings but could be helpful in others. To establish whether single factors (e.g., 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) [129,141,142,143,144] or combinations of these factors actually determine improvement of HCWs' adherence to hand hygiene requires further research. Ultimately, adherence to recommended hand hygiene practices should become part of a culture of patient safety in which a set of interdependent elements of quality interact to achieve the shared objective [145].

Impact of Hand Hygiene Promotion

The impact of strategies and/or campaigns to promote hand hygiene in healthcare settings can be measured primarily by

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monitoring hand hygiene compliance in daily care practice before and after the intervention. Over the past 12 years, several studies have demonstrated the effectiveness of such strategies on improving this process indicator, mostly based on a multimodal approach [107,113,114,116,120,135,146,147,148,149,150,151]. In most of these interventional studies, the introduction of alcohol-based handrubs at the point of care as a system change was the crucial component of the promotional strategy [107,113,114,116,120,135,146,147,148,149,150,151].

TABLE 3-4 STRATEGIES FOR SUCCESSFUL PROMOTION OF HAND HYGIENE IN HOSPITALS

Strategy Selected References* * Only selected references have been listed; readers should refer to more extensive reviews for exhaustive reference lists [1,54,128,142,173]. Adapted with permission from World Health Organization. WHO Guidelines for Hand Hygiene in Health Care (Advanced Draft). Geneva: World Health Organization, 2006. (http://www.who.int/patientsafety/information_centre/Last_April_versionHH_Guidelines%5b3%5d.pdf) accessed 19 July 2006. 1. Education 2. Routine observation and feedback 3. Engineering control Make hand hygiene possible, easy, convenient Make alcohol-based handrub available 4. Patient education 5. Reminders in the workplace 6. Administrative sanction/rewarding 7. Change in hand hygiene agent 8. Promote/facilitate skin care for HCWs' hands 9. Active participation at individual & institutional level 10. Improve institutional safety climate 11. Enhance individual & institutional self-efficacy 12. Avoid overcrowding, understaffing, excessive workload 13. Combine several of above strategies [107,110,112,113,114,115,116,117,119,121,136,137,156] [107,112,113,115,116,121,137,156,157] [107,114,115,116,119,136,156,158,159] [107,113,117,120,134,136,137] [120,160,161] [107,109,113,114,116,117,134,136,162,163,164,165] [117,141,142] [113,117,120,123,134,136,137,166,167] [107,166,168,169] [107,108,116,136,142,170] [107,108,116,136,142] [107,108,116,136,142] [107,123,139,171,172] [107,108,110,112,113,115,116,136,137,142]

It is evident that the most valuable method to demonstrate the impact of hand hygiene improvement is to detect a significant reduction of HAI rates in the study intervention setting. Unfortunately, a limited number of studies monitored the effect on this crucial outcome indicator because active surveillance of infection is highly resource demanding and complex to perform in a reliable manner (Table 3-5). Despite study limitations, most reports based on multimodal strategies, including the introduction of an alcohol-based handrub, showed a temporal relation between improved hand hygiene practices and reduced HAI rates. However, only a few reported a sustained effect over a prolonged period of time [107,117,152,153,154,155]. Although it remains important to generate additional scientific and causal evidence for the impact of enhanced adherence with hand hygiene on HAI rates, these results strongly suggest that improved hand hygiene practices reduce the risk of transmission of pathogenic microorganisms.

Global Perspective and Research Agenda

Poor compliance with hand hygiene affects facilities at any level of country development. Improvement relies not only on individual HCW awareness and knowledge but also on involvement at institutional and governmental levels, thus implying the need for system and policy changes. Recent or potential pandemics (e.g., severe acute respiratory syndrome [SARS] and Avian influenza) have amply demonstrated that standard precautions, including hand hygiene, are not implemented in an optimal manner in many healthcare facilities worldwide. In a global perspective, hand hygiene promotion may imply different approaches depending on where the intervention is conducted. In developed countries, the issue could be for hospitals to find innovative strategies for previous campaign reinforcement or the introduction of new sophisticated solutions, whereas in resource-poor facilities in developing countries, a stronger effort should be made to convey messages in the simplest way and to seek low-cost practical solutions. The recently issued WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft) and their implementation strategy represent an unprecedented effort to promote hand hygiene with an evidence-based approach adapted to local needs and resources in a global perspective [5].

Although the published scientific evidence on hand hygiene has increased considerably in recent years, many

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controversial issues remain unsolved. The main areas for research are optimal products and practical technique, clinical efficacy and cost effectiveness, and laboratory-based and epidemiologic models to link hand hygiene practices with microbial transmission, standardization of monitoring, and system evolution. From a global perspective of hand hygiene implementation, international experts acknowledge the need for field testing to identify practical solutions concerning water quality for hand hygiene, soap contamination during use, hand drying, microbicidal activity against Norwalk virus and multiresistant bacteria, hand hygiene and use/re-use of gloves, surgical hand antisepsis, and hand hygiene behavior and promotion in different cultural settings [5].

TABLE 3-5 ASSOCIATION BETWEEN HAND HYGIENE IMPROVEMENT AND HEALTH CARE–ASSOCIATED INFECTION RATES: HOSPITAL-BASED STUDIES, 1995–2005

Year Authors Hospital Setting Significant Results Duration of Follow-up ICU, intensive care unit; NICU, neonatal ICU; MRSA, methicillin-resistant Staphylococcus aureus; MICU, medical ICU. 1995 Zafar et al. [138] Newborn nursery Control of a MRSA outbreak using a triclosan preparation for hand antisepsis in addition to other infection control measures 3.5 years 2000 Larson et al. [108] MICU/NICU Significant (85%) relative reduction of VRE rate in the intervention hospital; statistically insignificant (44%) relative reduction in control hospital; no significant change in MRSA 8 months 2000 Pittet et al. [107] Hospitalwide Significant reduction in the annual overall prevalence of healthcare-associated infections (41.5%) and MRSA cross-transmission rates (87%). Active surveillance cultures and contact precautions were implemented during same time period. 5 years 2003 Hilburn et al. [174] Orthopedic surgical unit 36.1% decrease in infection rates (from 8.2% to 5.3%) 10 months 2004 MacDonald et al. [165] Hospitalwide Significant reduction in hospital-acquired MRSA cases (from 1.9% to 0.9%) 1 year 2004 Swoboda et al. [159] Adult intermediate care unit Reduction in health care–associated infection rates (not statistically significant) 2.5 months 2004 Lam et al. [114] NICU Reduction (not statistically significant) in health care–associated infection rates (from 11.3/1000 patient-days to 6.2/1000 patient-days) 6 months 2004 Won et al. [117] NICU Significant reduction in health care–associated infection rates (from 15.1/1000 patient-days to 10.7/1000 patient-days), in particular of respiratory infections 2 years 2005 Gordin et al. [152] Hospitalwide Significant reduction in nosocomially acquired MRSA (21%) and VRE (41%) 3 years 2005 Zerr et al. [153] Hospitalwide Significant reduction in hospital-associated rotavirus infections 4 years 2005 Rosenthal et al. [154] Adult ICUs Significant reduction in health care–associated infection rates (from 47.5/1000 patient-days to 27.9/1000 patient-days) 21 months 2005 Johnson et al. [155] Hospitalwide Significant reduction (57%) in MRSA bacteremia 36 months

Among the most important issues for research are the impact of specific hand hygiene indications on specific infectious outcomes and risk level in case of negligence, relation between compliance and infectious outcomes, impact of glove use on transmission between patients and within the same patient, and the most effective promotion strategies to guarantee sustained improvement.

Acknowledgments

The authors thank Rosemary Sudan for outstanding editorial support.

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