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Three-step hand hygiene protocol improves compliance

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November 7, 2018

In a clinical setting, a three-step hand hygiene protocol resulted in higher compliance with both hand hygiene technique and indications compared with the six-step method endorsed by WHO, according to study findings.

Writing in Clinical Infectious Diseases, Sarah Tschudin-Sutter, MD, MSc, a physician and researcher in the division of infectious diseases and hospital epidemiology at the University Hospital of Basel in Basel, Switzerland, and colleagues explained that hand hygiene compliance at most institutions remains “insufficient” despite multiple interventions. According to the study, health care-associated infections can be reduced by 6% with just a 10% improvement in hand hygiene compliance.

“The technique for the use of hand rub outlined in the WHO guidelines consists of six steps to ensure entire coverage of the hands,” Tschudin-Sutter and colleagues wrote. “A systematic review evaluating the evidence base for this technique for reducing the microbial load on the hands of health care workers provides evidence for its effectiveness but does not identify the most effective hand hygiene technique; furthermore, the recommended application time for hand rub has been challenged by a study demonstrating that a reduction in application time” — to just 15 seconds — “may result in improved compliance, while having a similar microbiological effect.”

Previously, Tschudin-Sutter and colleagues demonstrated the slight superiority that a three-step hand hygiene technique has over the six-step process in reducing bacterial load. However, the experimental study did not show the impact the technique may have in a clinical setting.

So they conducted a cluster-randomized trial from October 2015 to November 2015 at the University Hospital of Basel, a tertiary academic care center, randomly assigning 12 wards to either the three- or six-step technique. According to the study, the three-step process consists of covering all surfaces of the hands followed by rotational rubbing of fingertips in the palm of the alternate hand and rotational rubbing of both thumbs. Both the three- and six-step technique were performed for 30 seconds with 3 mL of hand rub, Tschudin-Sutter and colleagues explained. The primary endpoints were compliance with the assigned hand hygiene technique and a bacterial count reduction on health care workers hands.

Among 294 health care workers, Tschudin-Sutter and colleagues observed 2,923 hand hygiene indications with an overall compliance rate of 70.7% (n = 2,066). On wards assigned to the three-step technique, compliance with hand hygiene indications was 75.9% and technique compliance was 51.7%. On wards assigned to the six-step technique, hand hygiene indication compliance was 65% and compliance to technique was 12.7%, according to the study. Furthermore, when both techniques were compared, the reduction factor of bacterial counts did not differ (P = .629).

The study demonstrates noninferiority of the three-step hand hygiene technique as compared to the six-step protocol in a clinical setting. The researchers believe a simpler hand hygiene protocol could safely replace the current standard.

“We observed higher compliance with both hand hygiene technique and indications on wards assigned to a three-step as compared to the conventional six-step hand hygiene technique,” Tschudin-Sutter and colleagues wrote. “Further trials in other clinical settings are required to externally validate our findings.” – by Marley Ghizzone

Disclosures: Tschudin-Sutter reports being a member of the Astellas and MSD Advisory Boards for Clostridium difficile and reports grants from the Swiss National Science Foundation NRP72 (407240_167060), the Gottfried und Julia Bangerter-Rhyner Stiftung and the Fonds zur Förderung von Lehre und Forschung der Freiwilligen Akademischen Gesellschaft Basel, and reports grants from Jubiläumsstiftung von Swiss Life, outside the submitted work. Please see the study for all other authors’ relevant financial disclosures.

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Didier Pittet

What is important to say is that the technique is called the “three-step technique.” But in fact, it is not a three-step technique; it is a technique where the three most important steps for hand cleansing of the six steps that are described in the WHO strategy are used. The WHO method had been described to cover all surfaces of the hands, and it is sometimes a little bit difficult for people to keep in mind the complete sequence of the technique so the idea of [Tschudin-Sutter and colleagues] was to simply propose to insist on the three most important steps of the WHO six step-technique, and not worry too much about the others. But still, coverage of all surfaces of the hands was requested, which means that this is, in fact, the equivalent objective of the six-step technique, with further insistence on three of the steps; i.e. the most important. In particular, one of the steps calls for the rubbing of fingertips, and it probably is the most efficient at reducing bacteria on hands. Thus, the results are not surprising.

When you speak about compliance with when to clean your hands, it is very important. If compliance is 20%, this means that if you must visit five patients, you would clean your hands for only one patient. This is not good at all. In this study, what is called compliance is the compliance with the sequence of the technique that was proposed to study participants. Of course, if I ask you to retain in your mind six names of six cities or three names of three cities, it would be easier for you to recall three names of three cities than six names of six cities in the right order. It is an analogy to explain that it is not very surprising to observe a better respect of three steps, than of six, within a sequence of events. What is very interesting is to imagine that if we could demonstrate in the future that doing the six-step technique in any order — which is what we have proposed for a long time — or if you do a three-step technique that insists on the most important steps, that could be simpler for health care workers. The fact that it is simpler would eventually create more compliance with when to clean hands, but this has not been proven yet.

This paper does not change our practices. We are currently performing a meta-analysis of all the papers in which the technique has been studied to see what is the state of the technique. We proposed the six-step technique in 2009, and now we are in 2018. It was based on the testing of the alcohol-based hand rubs in the laboratory and we will follow the literature and the evidence in order to know if this is still accurate. Of course, this paper is important and will be included in the systematic approach that is conducted by WHO, and the revision, if any, will be proposed for the next World Hand Hygiene Day that is organized by WHO, which is on May 5 of every year. So, on May 5, 2019, if the technique based on the evidence needs to be revisited, we will propose a revision. That is the process at WHO. We review all the state-of-the-art literature, we summarize it, we call groups of experts, they listen to the summary and decide if the technique needs to be adapted or not.

There are other aspects of the hand hygiene technique that are extremely important. For example, the volume of alcohol that is used is 3 mL, which is a large volume of alcohol-based hand rub, for a relatively long duration, i.e. 30 seconds. Currently, there is evidence that you can probably do it in a shorter time (15 to 20 seconds), but again this is another discussion. Shortening the duration and ensuring a volume adapted to the hand size are probably the most important factors to ensure optimal antimicrobial efficacy.

What is good is that in 2009, when we published the WHO guidelines, we proposed a research agenda and this study is part of that. This is really good and helps to promote useful clinical research, and the authors should be congratulated.

Didier Pittet, MD, MS, CBE

Director, Infection Control Programme and WHO Collaborating Centre on Patient Safety
University of Geneva Hospitals and Faculty of Medicine
Lead advisor, Save Lives: Clean Your Hands, WHO

Disclosure: Pittet reports receiving funding from the European Commission and the Swiss National Science Foundation for several research and clinical studies and working with WHO in the context of the WHO initiative Private Organizations for Patient Safety.